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COPYRIGHT DEPOSIT. 



SYMPTOMATIC AND 
REGIONAL THERAPEUTICS 



SYMPTOMATIC AND 
REGIONAL THERAPEUTICS 



BY 



GEORGE HOWARD HOXIE, A.M., M.D. 

PROFESSOR OF INTERNAL MEDICINE AND DEAN OF THE CLINICAL DEPARTMENT 
IN THE SCHOOL OF MEDICINE OF THE UNIVERSITY OF KANSAS ; MEMBER 
OF THE AMERICAN ACADEMY OF MEDICINE, AMERICAN MEDICAL 
ASSOCIATION, ETC. ; PRESIDENT, 1909-1910, OF ASSOCIA- 
TION OF AMERICAN MEDICAL COLLEGES 



WITH FIFTY-EIGHT ILLUSTRATIONS IN TEXT 




NEW YORK AND LONDON 

D. APPLETON AND COMPANY 

1910 






X* 



Copyright, 1910, by 
D. APPLETON AND COMPANY 



Authority to use for comment the Pharmacopeia of the United States of America, 
Eighth Decennial Revision, in this volume, has been granted by the Board of 
Trustees of the United States Pharmacopeial Convention, which Board of Trus- 
tees is in no way responsible for the accuracy of any translations of the official 
weights and measures, or for any statements as to strength of official preparations. 



PRINTED AT THE APPLETON PRESS 
NEW YORK, U. S. A. 



(gCU26885l 



PREFACE 



The following pages contain the material collected for the 
course in general therapeutics recommended by the Committee on 
Curriculum of the American Medical Association — a recommenda- 
tion adopted also by the Curriculum Committee of the Association 
of American Medical Colleges. Inasmuch as the course forms a 
transition from the laboratory to the clinic, more attention is given 
to the discussion of the principles underlying the various methods 
of treatment than to an elaboration of the relative merits of the 

various drugs that have been recommended during the centuries 

* 

of development of the art of healing. 

The first part of the course is devoted to a consideration of 
symptoms and their relief; and of the relations of symptoms to 
pathological processes. The effort is made to keep in the student's 
mind the distinction, so often lost sight of, between symptomatic 
and specific treatment — and thus lead him to seek out in all cases 
the pathology of the disease. 

The same matter is looked at from another viewpoint in the 
second chapter, when the treatment of disease is discussed with 
relation to the therapy of inflammations. While the practical tech- 
nique turns out to be the same, the repetition of drugs and pro- 
cedures will be of advantage in fastening in the student's mind 
the details generally so hard to remember. 

Finally, in a general review of the pathology of the body, re- 
gion by region, the application of the principles already laid down 
is made to the various disease-entities that the student is meeting 



vi PREFACE 

in the clinics. This part becomes thus a working manual for the 
clinician and student. 

An appendix (Part III) of notes and memoranda on the drugs 
mentioned has been added to save the reader the need of constantly 
referring to some materia medica for dosage and officinal prepara- 
tions. It is hoped that this feature will make the book of value to 
practitioners as well as students. 

I wish to thank Professor Sollman for his kindness in suggest- 
ing the development of Chapter II; Dr. Samuel 0. L. Potter for 
permission to quote from his valuable Materia Medica; Dr. George 
H. Simmons for permission to use matter appearing in the Journal 
of the American Medical Association; Dr. R. T. Sloan for reading 
the manuscript on the diseases of the respiratory tract; Miss Elea- 
nor Maude Kibbey and Mr. John D. Bigger for valuable assistance 
in the preparation of the text and illustrations; and Dr. Broome, 
of D. Appleton & Co., for his suggestions and help in carrying the 
book through the press. 

G. H. Hoxie. 

Kansas City. 



CONTENTS 



PART I 
GENERAL THERAPEUTICS 

PAGE 

Chapter I. — Symptomatic Therapeutics 3 

I.— Pain 5 

Local treatment 6 

Hyperemia 8 

Massage 9 

Drug treatment 12 

Local anesthesia 15 

Hypodermic medication 19 

General anesthesia 25 

II.— Fever 29 

III.— Itching 34 

Ointments 35 

IV. — Insomnia 41 

V. — Constipation . .45 

Enemata 51 

VI.— Vomiting 52 

VII. — Hiccough 54 

VIII.— Cough 55 

IX. — Asthma 57 

X.— Shock 57 

XL — Emaciation 58 

XIL— Obesity 63 

XIII. — Convulsions 71 

Chapter II. — The Treatment of Localized Inflammations . . 75 

I. — Acute inflammations 75 

Poultices 77 

Elimination 82 

II. — Chronic inflammations 83 

1. Antiseptics 83 

2. Vaccination 85 

vii 



viii CONTENTS 

PAGE 

(a) Serum therapy for diphtheria ... 86 

(b) Vaccines 88 

3. Caustics 89 

III.— Inflammations of the skin 89 

1. Traumatic 90 

(a) Burns . . 90 

(6) Frostbite 93 

(c) Cuts . . . . . . . .93 

(d) Bruises .95 

(e) Abrasions .95 

2. Bacterial 95 

IV. — Inflammations of mucous membranes .... 100 

1. Accessible membranes 101 

2. Inaccessible membranes 103 

Drugs used 103 

V. — Inflammation of serous membranes .... 104 
VI. — Inflammation of muscles and tendons . . . .105 

1. Bruises 105 

2. Strain 106 

3. Myalgia 106 

4. Dystrophia 107 

VII. — Inflammation of the bones 108 



PART II 

REGIONAL THERAPEUTICS 

Chapter III. — Diseases op the Respiratory Tract . . . .113 

The Nose 113 

Acute rhinitis . 113 

Chronic rhinitis 115 

Epistaxis 116 

Hay fever 117 

The Throat 117 

Pharyngitis 117 

Tonsillitis 118 

Laryngitis . . . 122 

Spasmodic laryngitis . . 123 

Edema glottidis 124 

Diphtheria 124 

Intubation ' 127 

Tracheotomy ......... 131 

The Bronchi 134 

Bronchitis, acute . . , , , . > .134 

Broncho-pneumonia 137 



CONTENTS ix 

PAGE 

Bronchitis, chronic 140 

Bronchial asthma 143 

The Lungs 144 

Emphysema 144 

Edema 144 

Pneumonia 145 

Phlebotomy . . . 151 

Pleurisy 154 

Thoracocentesis 156 

Phthisis 164 

Climatic treatment 169 

Antiseptic treatment 176 

Symptomatic treatment 181 

Chapter IV. — Diseases of the Digestive Tract .... 188 

The Mouth 188 

Stomatitis 188 

Acute stomatitis 189 

Chronic stomatitis 189 

Traumatic stomatitis 190 

Thrush 190 

Aphthous stomatitis 191 

Ulcerative stomatitis . . . '. . . . 191 

Mercurial stomatitis 191 

Scorbutic stomatitis 192 

Pyorrhea 192 

Noma 192 

Geographical tongue . 192 

Leukoplakia oris 193 

The Esophagus 193 

Inflammation 193 

Stricture 194 

Spasm 197 

The Stomach .200 

Gastralgia 200 

Anacidity 201 

Hyperacidity 202 

Gastric ulcer 203 

Cancer 204 

Pyloric stenosis 205 

Portal congestion 206 

Neuroses 207 

Dilatation 208 

Gastric lavage 210 

The Liver 216 

Icterus 217 



x CONTENTS 

PAGE 

Hepatitis 220 

Cholangitis and cholecystitis 221 

Chronic cholecystitis . . 224 

Gallstones 225 

Gummata 226 

Cirrhosis . * 226 

Abscesses 228 

Hydatid cysts 228 

The Intestines 229 

Enteralgia . . t # . .229 

Enteritis 231 

Flatulence 233 

Typhoid fever 234 

Colitis .237 

Parasites 241 

Ameba 242 

Pinworm 243 

Round worm . . 244 

Enteroptosis 244 

Pancreatitis 245 

Peritonitis 246 

Hemorrhoids 250 

Fistulse and fissures 251 

Pruritus ani . . 253 

Chapter V. — Diseases of the Circulatory System .... 255 

The Heart 255 

Neuroses 255 

Pericarditis 257 

Myocarditis 260 

Endocarditis 262 

Constitutional diseases 266 

Schott movements 267 

The Blood Vessels 269 

Arteriosclerosis 269 

Apoplexy 270 

Varicose veins . 271 

Varicose ulcers 272 

Relaxed vessels 272 

Capillary hemorrhage 274 

Purpura 275 

Hemophilia 276 

Scurvy 276 

The Blood 277 

Primary anemia . . 277 

Pernicious anemia . . ,• 279 



CONTEXTS xi 

PAGE 

Secondary anemia 280 

Leukemia 280 

Trypanosomes 281 

Chapter VI. — Disorders of the Genito-urinary Tract . . . 282 

Uremia 282 

Oxaluria . 284 

Phosphaturia 285 

Acute nephritis 285 

Chronic nephritis 286 

Suppurative nephritis 291 

Degenerative nephritis . 292 

Renal calculus 292 

Cystitis 293 

Catheterization 294 

Enuresis 299 

Acute urethritis 300 

Chronic ulceritis 301 

Prostatitis 304 

Epididymitis 306 

Sexual neurasthenia . . . . . . . . 306 

Endometritis 307 

Salpingitis 308 

Oophoritis 308 

Bartholinitis ...'.' 309 

Chapter VII. — Disorders of the Nervous System .... 310 

Intracranial disorders 310 

Tabes 311 

Embolism 311 

Neoplasm 312 

Meningitis 312 

Sunstroke 312 

Hydrocephalus 312 

Infantile palsy 312 

Lumbar puncture 313 

Spinal disorders 317 

Chronic pachymeningitis 317 

Myelitis 317 

Anterior poliomj-elitis .317 

Tabes 318 

Tetanus 319 

Neuroses 320 

Mania 321 

Chorea 323 

Epilepsy 324 



xii CONTENTS 



PAGE 

Hysteria 325 

Neurasthenia 333 

Neuralgia 336 

Neuritis 337 

Beri-beri 338 



Chapter VIII. — Disorders of the Glands 339 

Lymphatic glands 339 

Acute lymphadenitis -. . 339 

Lymphatic anemia 339 

Venereal buboes 339 

Tuberculous glands 340 

The spleen 341 

Splenomegaly 341 

The adrenal bodies 342 

The pituitary body 342 

The thyroid gland 343 

Chapter IX. — Disorders of Metabolism 345 

Gout 345 

Arthritis 346 

Diabetes mellitus 349 

Rickets 361 

Chapter X. — Infectious Diseases 363 

Actinomycosis 365 

Anthrax 365 

Bacillary dysentery 365 

Chicken pox 366 

Cholera 366 

Yellow fever 369 

Erysipelas 370 

Glanders . . . . 371 

Hydrophobia 371 

Influenza 373 

Malaria 375 . 

Measles 375 

German measles 376 

Plague 376 

Scarlet fever 377 

Septicemia 378 

Smallpox 380 

Syphilis 384 



CONTENTS xiii 

PART III 
NOTES ON REMEDIES 

PAGE 

Chapter XL — Miscellaneous Notes 391 

Baths in common use 391 

Doses proportionate to age 392 

Substances excreted in milk . 392 

Alcohol table 393 

Percentage solution table 394 

Metric and apothecaries' equivalents 395 

Chapter XII. — Materia Medica 396 

Acetic acid 396 

Acetone 396 

Aconite 396 

Aloe .397 

Alum 397 

Ammonium salts 397 

Anise 397 

Antip3 r rine • . . . 398 

Apomorphin 398 

Argyrol 398 

Arnica 398 

Arsenic 399 

Asafetida 401 

Atropin 401 

Benzoin . 402 

Berberis 403 

Bismuth 403 

Boric acid 404 

Bromide 405 

Bromural 406 

Cade, oil of . . 407 

Caffein 407 

Calcium 408 

Carbo animalis 410 

Carbo ligni 410 

Cardamom 410 

Cascara sagrada 411 

Castor oil 411 

Chloral hydrate 412 

Chloroform 413 

Chloretone 413 

Citric acid 413 

Coal-tar derivatives 413 

Colchicum 415 



xiv CONTENTS 

PAGE 

Materia Medica. — Collodion 415 

Colocynth 416 

Co'ndurango . ' . 416 

Creosote 416 

Cresol, compound liquor 417 

Cupri sulphas . . . . ■ 417 

Digitalis 417 

Dormiol 419 

Dover's powder 420 

Elixirs .420 

Epicarin 421 

Epinephrin 421 

Ergot 422 

Ether 422 

Ethyl chlorid 423 

Eucain 423 

Eucalyptus 424 

Fibrolysin 424 

Formaldehyd 425 

Gelsemium . . . 425 

Gentian 426 

Guaiacol 426 

Hexamethylenamin 426 

Hydrastis 426 

Hydrogen dioxid 427 

Hyoscin 428 

Hyoscyamus 429 

Ichthyol 429 

Iodids 429 

Ipecacuanha 430 

Iron 431 

Kaolin 432 

Lactic acid 432 

Lysol 433 

Mercury 433 

Methylene blue 434 

Naphthol 434 

Nitrites . . . ' 435 

Nitrous oxid 438 

Opium 439 

Orthoform 442 

Oxgall 442 

Pancreatin 443 

Papain 444 

Peppermint 444 

Pepsin 445 



CONTENTS xv 

PAGE 

Materia Medica. — Permanganate of potash .,«... 445 

Petrolatum . 445 

Phenol 446 

Phenolphthalein . . 446 

Phosphorus 447 

Piperazin 447 

Pollantin 448 

Potassium compounds 448 

Quinin 450 

Resorcin 451 

Rhubarb 451 

Rochelle salts 451 

Sabromin 452 

Salicylates 452 

Saline solution 453 

Salol 455 

Sandalwood oil 455 

Santonin 456 

Senna 456 

Silver 457 

Sodium 458 

Starch 460 

Stramonium 460 

Strychnin 461 

Stypticin 462 

Sulphonal . 462 

Sulphur 463 

Syrup of orange 463 

Tannin 463 

Tars 466 

Theobromine 466 

Thiosinamin 467 

Thymol 468 

Thyroid extract 468 

Tolu 468 

Trichloracetic acid 468 

Turpentine 469 

Urea . 469 

Valerian 470 

Veratrum viride 470 

Veronal 470 

Mineral waters 470 

Wool fat 485 

Yohimbin .......... 485 

Zinc compounds 486 



LIST OF ILLUSTRATIONS 



FIG. PAGE 

1. — The Forth thermophore 8 

2. — Portable bath tub for the sick room 29 

3. — Ice bag for spine 30 

4.— Flat ice bag 30 

5. — Leiter coil for flat surfaces, such as chest 30 

6. — Leiter coil for the head 30 

7. — Massage of the colon for constipation 48 

8. — A portable tub 62 

9. — Hot-air cabinet, arranged for gas heat 71 

10. — Applying heat by means of a 500-candle-power electric light . . 80 

11. — The permanent bath 91 

12. — The application of heat by means of the high-candle-power lamp . 94 
13. — Application of zinc oxid adhesive bandage for muscular strain and 

myalgia 106 

14. — Position of hand and wrapped scalpel for incising peritonsillar ab- 
scesses 119 

15. — Intubation set 127 

16. — Intubation of the larynx 128 

17. — Technique of intubation 129 

18. — Tracheotomy tube 132 

19. — Trocar-pointed obturator for tracheotomy tube 132 

20.— Respirator 140 

21. — Turpentine pipe 141 

22. — Applying a clay poultice 145 

23. — Covering the clay poultice with the cotton jacket 146 

24. — Fomentation to the back of the chest 149 

25. — Median vein 151 

26. — Conditions in which the aspirating needle fails to withdraw fluid . 158 

27. — The Potain type of aspirator 159 

28.— The Truax aspirator . . . . . . . . . . . .160 

9 

6 XV11 



xviii LIST OF ILLUSTRATIONS 

FI »- PAGE 

29. — Points recommended for the insertion of the aspirating needles . 162 

30. — The Mosny-Stern apparatus for aspirating a "blocked" pleurisy . 163 

31. — Cohnheim's apparatus for dilating the cardia 198 

32. — Trousseau's bougies 198 

33. — Pouche sous-pylori que of Chapotat 209 

34. — Original method of gastric lavage without the help of a physician . 210 
35. — Ordinary type of stomach tube with funnel and bulb . . . .211 

36. — Pulling the larynx forward before inserting the tube . . . . 212 

37. — Stomach washing in adults 214 

38.— The Ewald tube . .215 

39. — Esophageal stricture 216 

40. — Electric bath cabinet room 219 

41. — Manner of holding trocar ' 228 

42. — Apparatus for continuous proctoclysis 248 

43. — The various limits of the left pleura . 259 

44. — The sinus prostaticus 294 

45. — Obstruction at the mouth of the urethra 295 

46. — Obstruction offered by the sphincter 295 

47. — Catheter obstructed by the sinus pocularis 295 

48. — Method of pushing catheter out of the sinus pocularis .... 296 

49. — Metal catheter for normal cases 296 

50. — Metal catheter for enlarged prostate 297 

51. — Position for passing catheter under pubic arch 297 

52. — Position of catheter after it has entered the bladder .... 298 

53. — Treatment of the prostate through the urethra 304 

54. — Treatment of the prostate through the rectum 305 

55. — The spaces for lumbar punctures 314 

56. — The permanent bath for quieting mania 322 

57. — The permanent bath in use in a hospital for the insane . . . 322 

58. — The two methods of vaccination 383 



PAET I 

GENERAL THERAPEUTICS 



CHAPTER I 
SYMPTOMATIC THERAPEUTICS 

INTRODUCTORY 

To treat a patient successfully the. physician should learn, if 
possible, the pathological process present (the pathological physi- 
ology, as some use the term), and then either (a) remove the cause, 
or, if that be impossible, (6) check or change the processes so as 
to bring relief to the patient. Thus, in the palpitation and gas- 
tritis of the tobacco user, one can easily correct the condition by 
stopping the use of tobacco. But in the palpitation and gastritis 
incident to enteroptosis one cannot remove the cause, and it then 
becomes necessary to change the habits of life and the diet, and 
to give drugs to get rid of the irritation proceeding from the nerve 
plexuses of the abdomen, either by depressing these reflex arcs 
or by stimulating the heart action and the digestion so that these 
reflexes no longer upset the rhythmic action of these organs. Hav- 
ing then determined the point of attack (whether, for example, 
the reflex arcs or the organs themselves), we can select intelligently 
the therapeutic agents needed. 

The work of the pharmacologists of the last quarter century has 
thrown great light on the action of the drugs composing our 
materia medica. We have learned, among other things, that many 
plants and drugs have as essential elements but variations of one 
single active principle, and that physicians have been championing 
practically identical active principles even when they have been 
disputing about the merits of their favorite prescriptions. Thus, 
atropin has been the basic principle for those who have sworn by 
the virtues of the Jimson weed as well as for those who repudiated 
the Jimson weed and chose for themselves the deadly nightshade 
or henbane. Again, the homeopath who used spongia in croup was 
really giving the same drug as the man who used iodized calcium. 

3 



4 SYMPTOMATIC THERAPEUTICS 

Hence, there is great need of revising our drug lists and select- 
ing from them for our use those active principles that have proved 
their worth and whose action is known, and then of using those 
active principles in the dosage appropriate to the result we desire 
to obtain, as our fathers did when they used the crude drugs 
which contained these same active principles, although in varying 
proportions. Thus, atropin may be used in dosage appropriate 
for flushing the skin, or for checking the sweat, or loosing a spasm 
of the peristaltic mechanism. The physician of the older school 
could have used belladonna, agaric, and hyoscyamus for the re- 
spective purposes. 

Proceeding on this principle, it has been found that only a com- 
paratively few drugs are needed in the ordinary practice of medi- 
cine — provided that the physician knows all about the action of 
these few. Thus, it is not sufficient to know that atropin causes a 
rapid heart beat or dries the throat ; it must be known how it does 
this. To be sure, our laboratories have not finished their work of 
studying our drugs for us, but enough has been done to justify our 
learning therapeutics from the new standpoint. Hence, in this text 
we emphasize everywhere the physiologic action of our drugs and 
endeavor to point out the work to be accomplished by each. 

Furthermore, the physician must not deceive himself and be- 
lieve that he is proceeding causally when he is merely checking the 
mechanism bringing about the symptoms — as in giving morphin 
in appendicitis — because, as in the disease instanced, such self- 
deception may make him indeed a blind leader of the blind, with 
the proverbial result. Very often we must proceed symptom- 
atically — for we must quiet pain and relieve distress long before 
we can learn, in a new case, all the train of events that led up to 
the present outbreak. Hence, it would be a mistake for our young 
laboratory-trained physicians to scoff — as many of them do — at 
symptomatic relief and leave their patients to suffer while they go 
away to make blood counts and urine analyses. The careful and 
accurate noting down of the symptoms presented — relieving the 
patient of his suffering as much as we can, while we proceed with 
a deeper study of the ease, will enable us to maintain our self-re- 
spect as scientific physicians and at the same time please our 
patrons, who generally judge us by the quickness with which we 
afford them relief. 



PAIN 5 

Hence, in our study of symptomatic therapeutics, we endeavor 
to trace out the functions or processes that are defective and lo- 
cate, whenever possible, the point of irritation — or at least the 
point to which treatment should be applied — and then select the 
remedy best adapted to do the work. The fine art of therapeutics 
consists in securing as specific an action as possible — not to affect 
the whole body when we wish simply to relieve pain in the finger, 
for instance — and thus interfere as little as possible with the nor- 
mal bodily processes. 

I. PAIN 

Pain may be caused by an irritation in the course of a sensory 
nerve, or it may be referred to such a nerve even though the irri- 
tant does not actually touch the nerve. Therefore, since the treat- 
ment in the different cases would vary greatly, it is important for 
the therapeutist to determine the location of such an irritation; 
that is, whether it lies near the nerve center, along the trunk, or 
at the end organ. This cannot be ascertained from the apparent 
location of the sensation, for in any case the pain is referred to 
the place where the end organ lies. To illustrate these statements : 
the pain of trigeminal neuralgia may seem to be in the face or 
teeth, but we usually find the irritation either in the nerve trunk 
or the ganglion. Again, an inflammation or disturbance in the 
cavum tympani may cause a toothache. Similarly, a cholecystitis 
may give rise to a pain in the back or the shoulder. A hernia ob- 
turatoria presents a pain radiating down the inner aspect of the 
thigh toward the knee. Renal calculus causes a pain running the 
whole length of the ureter, and even extending to the end of 
the urethra. Headache may be due to a tumor at the base of the 
brain, but is nevertheless felt as if in the periphery or even in 
the scalp. Because of this reference of pain, causal treatment can 
be effective only when the location of the irritation is known, and 
then only when the irritant can be removed. 

In the present state of our knowledge, this removal cannot al- 
ways be accomplished. Therefore, very frequently we must have 
recourse to symptomatic treatment in our effort to relieve pain. 
This type of treatment aims at relief rather than at cure. It is 
accomplished in one of three ways: (1) We inhibit the end organ 
of the sensory nerve, so that the sensation is not started out. Thus, 



6 SYMPTOMATIC THERAPEUTICS 

in a raucous ulcer, it is the exposure of denuded nerve endings 
that causes the pain. If these are deadened by the application of 
a local anesthetic, the pain ceases. (2) The nerve trunk may be 
blocked so that the sensation cannot be transmitted. Thus, for 
small surgical operations, injecting cocain along the nerve trunk 
prevents the sensation of pain from reaching the sensorium. 
Spinal analgesia, wherein a local anesthetic is injected into the 
spinal canal to stop the pain in operations below the diaphragm, 
is also an instance of this form of relieving pain. And (3) the 
sensorium may be so depressed that it does not perceive the sensa- 
tion of pain. Thus, morphin or the coal-tar derivatives inhibit the 
cortical centers, and the unpleasant sensations are not perceived — 
although the irritation in the periphery continues as before. 

Local Treatment 

There are several kinds of local treatment for the relief 
of pain, and these sometimes are causal, sometimes symptomatic, 
but always empirical. Thus, heat is applied to the spot where the 
pain seems to originate. This treatment is most effective in those 
cases where a local hyperemia will remove the irritation. But 
there is some relief in nearly every case. Therefore the local ap- 
plication of heat is usually the first attempt at treatment made 
both by doctor and layman. The simplest method of applying heat 
is the use of the hot-water bottle or other heated object. One can 
secure a longer continuance of such heat by using an incandescent 
electric light over the painful area, the details of the use of which 
are given below, or, if that be not at hand, by using a rubber 
water bottle full of sodium acetate which has been immersed in 
boiling water for ten minutes. Bags of sodium acetate thus treated 
will remain at a temperature of 150° to 170° F. all night, while 
they gradually discharge their heat of liquefaction. Still another 
variation is the application of a combination of waxes and rosins, 
which shrink as they cool, thus furnishing both heat and com- 
pression. This combination has been given the trade name of 
Tambrine or hyperthermaline. 

Somewhat more effective for circumscribed areas of inflamma- 
tion is the application of the moist and hot bandages or hot 
poultices. The first consists in applying bandages wrung out in hot 



PAIN 7 

water and covering them with some impermeable covering, such 
as gutta-percha tissue, oiled silk, or even waxed (paraffin) paper. 
For example, in a case of tonsillitis, a moist bandage should be 
wrapped around the neck — covering the whole area from the ear 
to the shoulder — and this covered with a dry bandage, or, better, 
oiled silk or muslin. In the original form, as devised by Priess- 
nitz, the bandage was cold (that is, the inner part was moistened 
in cold water) when applied. It then became heated by the body 
heat. But nowadays the bandage is more often applied hot. This 
bandage must be removed and renewed as soon as it becomes cold 
or loose. The second application is best illustrated in the clay 
poultice (the Cataplasma Kaolini of our Pharmacopeia), which 
holds the heat well, and, since it contains both glycerin and methyl 
salicylate, has added power for the relief of pain. The habit of 
the laity of using poultices has brought with it many sad results, 
because there is considerable danger from the use of dirty poul- 
tices. Thus, eyes have been infected by the application of raw 
meat, and skin infection has been added to the original disorder 
when bread-and-milk or linseed poultices have been used to re- 
lieve pain. Hence our belief that it is usually best to employ the 
clay poultices (known best in the form of antiphlogistine), because 
this is both sterile and clean. Such poultices must be applied hot 
and must be removed as soon as dry. They must be thick enough 
to retain the heat if they are to be effective. 

When intense backache is to be attacked a modification may be 
employed as follows : The patient may be stripped and made to lie 
in a warm room on a warm flannel blanket, then cloths wrung out 
in water as hot as can be borne are laid on the patient's back along 
the spine. After about three minutes these are removed and ice 
is rubbed over the same area. Then another hot cloth is ap- 
plied, and so on in alternation for one half to three quarters of 
an hour. Such treatment must, of course, be promptly discon- 
tinued should the patient fail to react, that is, if he should become 
chilled. 

When considering the various methods of applying heat we 
should not forget the sand bag, because that material is cheap and 
the bags can be thoroughly sterilized. They should be made into 
sizes and shapes adapted to the part of the body to be treated. 
Moreover, it is well to have many bags, so that a limb can be com- 



8 



SYMPTOMATIC THERAPEUTICS 



pletely surrounded with them. They are specially useful in neu- 
ritis and rheumatism. 

In using the ordinary incandescent electric light we attach to 
a sixteen-candle-power lamp a metal reflector (preferably in the 
form of a cone), and rest the edge of this reflector on a moistened 
towel which surrounds the painful area. In most cases it is well 

to have no cloth between the light and 
the skin. The whole should then be 
covered by a blanket or towels to re- 
tain the heat. There are on the mar- 
ket pieces of apparatus called photo- 
phores or thermophores, which have 
stands and adjustable arms, so that 
they can be applied to any part of the 
body and at any distance. The ad- 
vantage of the electric light is that it 
produces considerable heat without in- 
juring the skin, and can be applied or 
removed instantly and with little or 
no trouble. 

Hyperemia. — The introduction of 
local hyperemia for relief of pain 
and cure of local infection has been 
brought to scientific excellence by Pro- 
fessor Bier, now of Berlin. Thus it 
has become rational, and, since the laws 
governing its efficiency are becoming 
known, it is also losing its empirical character. This hyperemia 
is produced either by vacuum or by stasis. The first is accom- 
plished by using glass suction cups, like the cups for bleeding of 
former generations, shaped to fit the surface to be treated. In the 
smaller cups the vacuum is maintained by rubber bulbs, in the 
larger by pumps. These cups are applied to the painful area for 
from three to five minutes, then removed and the area allowed to 
rest for an equal period. The length of a treatment is usually 
forty-five minutes. Treatments may be repeated several times a 
day if need be. 

In the other method of producing hyperemia — applicable only 
to the extremities — an elastic ligature is thrown around the limb 




Fig. 1. — The Foutch Thermo 
phore. 



PAIN 9 

just tight enough to retard the superficial venous flow. This, when 
applied aright, can be kept on continuously for from twenty-four 
to forty-eight hours. Of course, the extremity should be at rest as 
nearly as possible during the treatment. This form of treatment 
seems to be especially well adapted to tuberculous joints. 

Massage. — Great relief from the more chronic sorts of pain can 
often be obtained by massage. Of massage, there are four primary 
movements — stroking, friction, kneading, and percussion. The 
movement should be toward the heart, beginning at the extremity 
and working toward the trunk, in order to assist in quicken- 
ing the circulation of the body fluids. Of course, massage can- 
not be used where there is tenderness, or where the movement is 
liable to cause a breaking down of tissue or hemorrhage. Hence 
considerable knowledge of the pathological condition is needed 
by one who would prescribe this form of treatment. It is best 
adapted to functional troubles, such as strains, nervous exhaustion, 
fatigue, and lethargy. Shoemaker gives the following description 
of these various movements: 

Stroking is done with the whole palm, with the radial border of the 
hand, or with the thumb or ends of the fingers. The pressure may be as 
light as possible, and vary gradually from this to as much weight as 
can be borne, the operating hand being reenforced by pressure made 
upon it with the other, or the weight of the other parts of the body may 
be called into play to give sufficient force to the stroke. The direction 
is nearly always venous (centripetal, or toward the heart), but in rare 
cases it may be arterial (centrifugal, away from the heart). 

Friction consists in more or less forcible circular rubbing of a sur- 
face, with the palm of the hand usually, or with the fingers or final 
phalanx of the thumb. During the manipulation the remaining fingers 
of the hand, or it may be of both hands, clasp the limb which is under 
treatment, making it a point of support. It is advisable to begin at 
the border of the pathologically altered tissues, and work out the exu- 
date into the surrounding healthy tissue in all directions, always con- 
cluding, however, with centripetal strokings. 

Kneading. — This is what is meant by " massage," which, however, 
as an English word is now used in a comprehensive sense to include all 
the manipulations in manual mechano-therapy and is applied to such 
treatment, even though kneading proper be not included in the pre- 
scription. The restricted application of this term is to the method of 
picking up or grasping a certain portion of muscle or other tissue with 



10 



SYMPTOMATIC THERAPEUTICS 



the fingers of one hand and subjecting it to pressure between them, or 
upon a hard substance such as a surface of a bone. Dr. Douglas Graham, 
of Boston, who is especially skilled in massage, recommends that in 
kneading " a group of muscles should be systematically worked upon, 
and for this purpose one hand should be placed opposite the other; or 
when the circumference of the limb is not great, one hand may be 
placed in advance of the other, the fingers of one hand partly reaching 
on to the territory of the other, so that two groups of muscles may be 
manipulated at the same time, with grasping, circulatory, spiral manipu- 
lations, one hand contracting as the other relaxes, the greatest extension 
of the tissues being upward and laterally, and on the trunk, forearms, 
and legs, away from the median line. ... It is well first to go over a 
surface gently and superficially before doing the manipulation more 
thoroughly and in detail." For instance, to take up a limb of consid- 
erable size, such as a leg, he finds three divisions of surface necessary: 
the posterior and lateral aspects will form one; the stretching of the 
peroneal muscles from those of the anterior tibial region will make 
another; and for the third a rolling of the tissues will be made away 
from the crest of the tibia. " In large muscular masses we seize them 
in successive portions with both hands and squeeze in all directions, 
as one would squeeze water out of a sponge," says Reibmayr. At the 
moment of making pressure a certain amount of longitudinal traction 
may be practiced, which adds to the value of the manipulation. An- 
other, but much less effective form of kneading consists in rolling the 
limb between the palms of the hands. The movements here are very 
rapid and the pressure less important, the principal effect being pro- 
duced by the frequently recurring stretching and forcible separation of 
the individual muscles, fasciae, and nerves. 

Vibration is a form of massage, the alternate pressure and relaxa- 
tion being made with great rapidity. It is generally performed by means 
of a mechanical contrivance by which any portion of the body or limbs 
may be thrown into vibration at the rate of several hundred per 
minute. Electrically driven instruments are now generally used. There 
are two general types and many variations of each type. Thus the 
whole body may be shaken by shaking rhythmically the chair or bed. 
On the other hand the tissues of a circumscribed area may be alter- 
nately compressed and released by small vibratodes which have either 
an oscillatory or a percussion stroke. This latter type is described more 
in detail below. 

Vapor Massage. — By the use of compressed air, fluids may be nebu- 
lized and driven with considerable force against the surface of the body. 
Ordinarily, the objects sought after are the removal of adherent mucus 



PAIN 11 

from the upper air passages and the application of medicated solutions; 
but excessive force is injurious. An apparatus has been devised by 
which the pressure can be regulated and made intermittent and the 
spray given at any desired pressure, or to have a vibratory effect, pro- 
ducing results similar to manual massage. Vapor massage has proved 
to be especially useful in the affections of the nose, throat, middle ear, 
and bronchial tubes. 

Percussion may be performed either with the border of the hand, the 
tips or knuckles of the fingers, the closed fist, or with some instrument 
constructed for the purpose. The shocks should be rapidly, but not for- 
cibly, delivered— usually from the wrist only. For this purpose various 
instruments have been invented, such as those above referred to. They 
are now so perfect that the. force and length of stroke can be accurately 
gauged and thereby deep or superficial tissues affected. Usually one 
should not work over any one area longer than five minutes. This is 
sufficient to deaden the hyperesthesia and produce hyperemia. After 
massage has been performed active and passive movements of the neigh- 
boring joints are usually resorted to, especially in case of diseased joints 
and in chronic cases with stiffened articulations. In the north of 
Europe massage has been systematically combined with Swedish reme- 
dial gymnastics (so-called movement cure) with great advantage. In 
this method various kinds of gymnastic exercises are resorted to, and 
peculiar forms of apparatus (such as the so-called Zander apparatus) 
are provided to meet various requirements of treatment. 

Electro-massage. — A massage electrode, in the form of a small roller, 
affords an excellent means of combining the effects of electricity and 
massage. It is usually connected with the faradic apparatus, but in 
cases of paralysis or exudation it might be very advantageously used 
with galvanism. 

As can be inferred from the above description of the move- 
ments, massage stimulates the lymphatic and venous circulation — 
and, secondarily, the arterial — thus being most useful where active 
hyperemia is needed. We use it, therefore, somewhat causally and 
somewhat symptomatically for paralyses, for parts immobilized in 
splints, and for obesity — in short, wherever we wish to stimulate 
the active nutrition as well as to relieve the pain. 

Hot Air. — This is another measure for relief of pain. The 
cabinet is akin to the thermophore, but enables us to utilize higher 
temperatures and secure something more than merely symptomatic 
relief. The body, or that part of it to be exposed, is wrapped 



12 SYMPTOMATIC THERAPEUTICS 

loosely in three or four folds of coarse (the so-called Turkish) tow- 
eling and inserted into the cabinet. The temperature of the in- 
terior of the cabinet is brought to 250° to 350° F. and kept there 
for one half to one hour, or at least until the forehead of the pa- 
tient has been bathed in perspiration for ten minutes. Then the 
cabinet is removed and a rub with tepid water given. This treat- 
ment relieves muscular and neuritic pains in a very satisfactory 
manner. 

So much for the various nonpharmacal procedures that are 
used for the relief of pain. As may be inferred from the descrip- 
tion, these measures are usually palliative and secondary to other 
and more forceful remedies. Their special value lies in cases of 
weakness, nervousness, and neurasthenia, where the weakened nerv- 
ous system prevents the patient's withstanding slight irritations 
and disorder which in health he would not feel as pain, but simply 
as discomfort. Since they can be applied and removed quickly, 
and since their effects practically cease with their removal, 
mechano-therapeutics are usually to be preferred to the more sys- 
temic and permanent pharmacal agencies whenever they are 
equally effective. 

Drug Treatment 

When we come to study the relief of pain by deadening the 
end organs of the sensory nerves, we find that, although heat and 
vibratory massage often accomplish this result, in many cases we 
must depend upon the use of drugs. Thus, the application on a 
pointed probe, covered with absorbent cotton, to a mucous ulcer of 
ethyl (or grain) alcohol in ninety-five-per-cent strength may cause 
a momentary increase in the pain, but is followed very shortly by 
a numbness that may persist for hours, and that is experienced as 
grateful relief. Similarly a probe dipped in a ten-per-cent aque- 
ous solution of nitrate of silver will sear over the denuded area, 
destroy the bacteria, and relieve the pain. This latter drug is more 
escharotic than the alcohol, and forms a hard scab and hence does 
not penetrate deeply. Where deeper action is desired, liquefied 
(ninety-five per cent) carbolic acid, which forms a soft scab and 
therefore affects the underlying tissues, is touched to the spot in 
the same way, and after the exposed tissue is whitened, the excess 
is wiped off with cotton moistened in alcohol. The value of the hard 



PAIN 13 

scab is in its protection of the underlying nerves and blood vessels. 
The nitrate of silver is therefore to be preferred in all cases of 
mucous ulcer where we have no reason to believe that the underly- 
ing tissues are infected or necrotic. This would be generally in 
cases of abrasion. On the other hand, where the ulcer is due to a 
vegetable microorganism (such as oi'dium albicans), the carbolic 
acid, which penetrates deeply, is to be preferred. The student 
should use the strong carbolic acid for this work, and never the 
five-per-cent solution. Both of these drugs destroy the tissue with 
which they come into contact. Hence, it is not a matter of merely 
inhibiting the end organ when using them. For this reason, also, 
we should not use the carbolic acid when we are not willing to 
destroy the nerves in the tissue underlying the ulcer. 

Sometimes one would prefer to use a powder to overcome the 
pain of an exposed nerve, as in ulcus cruris or in crushing in- 
juries. In such a case the pulvis antisepticus of the National For- 
mulary proves quite successful. Its formula follows: 

Phenol 

Eucalyptol 

Menthol 

Thymol aa 0.1 grams. 

Salicylic acid 0.5 " 

Zinc sulphate 12.5 " 

Boric acid 86.6 " 

In this combination the zinc sulphate acts as an astringent, while 
the boric acid is chiefly a vehicle. The salicylic acid is somewhat 
analgesic and antiseptic, but it also softens epidermal tissues. 

Bismuth subnitrate is another drug that is used for local anti- 
sepsis and analgesia. This may be used with zinc oxide and chalk 
in any convenient proportion. 

If we are dealing with a painful area of the intact skin, we 
must find a sedative analgesic drug that will be absorbed through 
the skin without injuring it; and for this we find atropin, menthol 
(or the other camphors), aconite, etc., available. But we must 
be careful to choose a drug and dosage that will not give a systemic 
toxic effect when used in this way. Hence, five-per-cent oil or alco- 
holic solutions of menthol are very popular, because their applica- 



14 SYMPTOMATIC THERAPEUTICS 

tion does not run the risks connected with the more toxic atropin 
or aconite. So, also, is methyl salicylate (oil of wintergreen), 
when diluted with an equal quantity of olive oil. All of these 
remedies give the greatest relief when, instead of being simply 
smeared on the surface, they are rubbed in thoroughly and the 
part covered with an impermeable bandage (e. g., paraffin paper) 
to prevent evaporation. 

For local use atropin is generally prescribed in the form of 
the unguentum belladonna? (ten per cent) because it is difficult to 
make an ointment with the alkaloid itself that would not be danger- 
ous when handed over to a layman to use on himself. This oint- 
ment is indicated more especially in cases of pruritus and pares- 
thesia. 

This mention of the unguentum belladonna? brings up the ques- 
tion of the relative value of ointments, aqueous solutions, and al- 
coholic solutions. As may be inferred from the preceding para- 
graph, a strong alcoholic solution is bound to destroy tissue, and 
one who uses it freely on his hands will find the skin becoming 
hard, cracking, and finally peeling off. Hence, we should avoid 
alcoholic solutions where we do not desire this result. The advan- 
tage of alcohol as a solvent or vehicle lies in its universality and 
the quickness with which it penetrates the skin. For this reason 
a five-per-cent solution of menthol in alcohol affords almost instan- 
taneous relief from itching, even when but slightly rubbed into the 
intact skin. On the other hand, it would be painful to sensitive 
parts, and when applied freely would lead to peeling (desquama- 
tion). Aqueous solutions are less prompt in their action, but have 
no effect on the skin beyond that of the contained drug. Glycerin 
has the advantage of being of itself easily absorbed by the skin, 
but it sometimes is slightly irritant. The ointments, on the other 
hand, are sedative because they protect the skin from the air, 
and, if made of the right materials, are not only not injurious, but 
preserve the skin and promote the absorption of the contained 
drugs. But they are greasy, and for that reason often objected to. 

The fact that the phenols and camphors are but slightly soluble 
in water restricts of itself the use of aqueous solutions for the 
application of analgesics. Hence, we find that most of the local 
remedies for pain contain enough alcohol to make a good solution 
and enough water to prevent the injurious effects of the alcohol; 



PAIN 15 

or they are ointments with a wool- fat base (because wool-fat is the 
one ointment base that is easily absorbed). Thus, the popular ap- 
plications for bruises, tincture of arnica or witch hazel, contain 
enough alcohol to be sedative, even if they did not contain any 
other active ingredients. Again, the analgesic balm of Dr. Bengue 
is a wool-fat ointment containing menthol, methyl salicylate, etc., 
in appropriate percentage. 

We can make as an illustration of these principles the two fol- 
lowing prescriptions for the relief of pain where the skin is intact : 

31. 

Menthol 2.5 grams. 

Methyl salicylate 10.0 " 

Alcohol 15.0 " 

Glycerin 15.0 " 

Sig. Rub into the painful area with gentle pressure. 

1*2. 

Menthol 5.0 grams. 

Methyl salicylate 5.0 

Camphor 5.0 

Wool fat 30.0 

White wax 10.0 

Paraffin 10.0 

M. f. ung. D. S. Apply to painful area. 

The use of such applications will be found indicated in rheu- 
matism, myalgia, neuritis, neuralgia, and even in forming boils. 
If the application of these drugs is followed by the use of the ther- 
mophore or hot-air bath, the sedative effect of the drugs is in- 
tensified. 

For merely temporary relief, eocain (in two- to ten-per-cent 
solution) may be applied to the mucous membranes. The drug, 
however, is too toxic to be handed over to a patient for continued 
use, and should be kept in the physician's hands for use in dead- 
ening the pain of small operations. 

For deadening the nerve trunk, eocain, or one of its substitutes, 
is practically the only drug used. Cocain deadens any part of 



16 SYMPTOMATIC THERAPEUTICS 

the nerve with which it is brought into contact. Hence, we may 
use it to deaden the end organs in mucous membranes, to deaden 
the nerve fibers, and, could we get at them, the nerve centers them- 
selves. For application to mucous membranes, cocain is applied 
with a spray or swab dipped in one- to ten-per-cent solution, be- 
cause the absorption of cocain solution from mucous membranes 
is so rapid that simply painting the surface with it is sufficient to 
produce an anesthesia sufficient for slight operations. For opera- 
tions on the eye, nose, or throat, adrenalin chlorid is frequently 
added to the cocain or eucain (a substitute for cocain) solution 
in order to secure constriction of the blood vessels and freedom 
from hemorrhage during the progress of the operation. For this 
purpose a 1 : 10,000 solution of the adrenalin is sufficient. 

When using cocain for injection into or under the skin, one 
should always remember that one grain of the drug is the limit of 
safety. Hence, of a one-per-cent solution only four syringefuls 
of 25 minims each can be used if it is liable to be all absorbed. 
This fact explains why less toxic substitutes are being sought for. 
Of such substitutes beta-eucain is still the one most generally used. 
With it a very good formula for infiltration anesthesia is the fol- 
lowing : 



Beta-eucain 0.1 gram ; 

Adrenalin chlorid (1 : 1,000) 8 drops; 

Normal saline solution 100.0 e.c. 



With such a solution, quite severe operations may be performed. 
The operation takes somewhat longer than with general anesthesia, 
because each layer of tissue must be anesthetized before it is cut 
into. But for patients with whom it is inadvisable to use general 
anesthesia, this method has proven both safe and, relatively speak- 
ing, pleasant. 

When the location of the painful area is such that it is im- 
practicable to reach all the nerves supplying it with one or two 
syringefuls of cocain, the other method, that of infiltrating the 
skin, is employed. Thus, when we wish to resect a rib in empy- 
ema, we prefer infiltration to simple nerve blocking. This method 
has been brought into logical and usable form by Schleich, whose 
formulae are: 



II 


III 


0.1 


0.01 


0.025 


0.005 


0.2 


0.2 



PAIN 17 

Solution I 

Cocain 0.2 

Morphin 0.025 

Sodium chlorid 0.2 

Five-per-cent phenol . . 5 drops 5 drops 5 drops 
Water (sterile) 100.0 100.0 100.0 

The solution selected is injected into (not under) the skin of the 
area to be incised. If the skin on the proximal side be thoroughly 
infiltrated first and the nerve trunks blocked, the injection of the 
rest of the area is not nearly so painful. The anesthesia appears 
in from three to ten minutes and remains usually some thirty 
minutes. Hence, one has time to perform any ordinary operation. 
Nerve trunks are also blocked in neuritis (e. g., sciatica) by 
injecting into or about the sheath of the nerve alcohol or other 
solution, some using the simple normal salt solution. The latter 
seems just as successful as the former. One selects for the place 
of puncture the point where the nerve is most easily reached prox- 
imal to the painful area. The skin is disinfected with hot water 
and soap, then alcohol and ether. The sterilized needle is then 
plunged into the sheath; should no blood escape from the butt of 
the needle, or no other disturbance result, the syringe is attached 
and the solution slowly injected. The needle is then withdrawn 
and the place covered with hot cloths for a few minutes, and sealed 
with collodion. Should blood escape, or the puncture prove too 
painful, the needle is withdrawn and inserted elsewhere. Of the 
normal salt solution one uses 80 to 120 c.c. at body temperature, 
or 10 to 20 c.c. at zero centigrade. Of the beta-cocain salt solution 
recommended by Schleich (cocain hydrochlor., 0.1; morphin hy- 
drochlor., — 0.02; sodium chlorid, 0.2; aqua. dest. ad 1,000) one 
uses 60 to 100 c.c. at body temperature. The alcohol is used at 
•seventy to eighty per cent strength, and 1 or 2 c.c. in quantity. 
Disastrous results have followed its use in sciatica, and it is there- 
fore to be used only when the other and less toxic solutions have 
proven unsuccessful. (Hecht, Journal A. M. A., Feb. 6, 1909.) 

To locate the sciatic nerve we can ' ' draw a line from the sacro- 
coccygeal joint to the postero-external border of the great trochan- 
ter; at the junction of the inner one third and the outer two 
thirds of this line is found the spine of the ischium. Placing the 



18 SYMPTOMATIC THERAPEUTICS 

needle a thumb's breadth to the outer side of this spine, and pene- 
trating in a directly perpendicular line to a depth varying from 
4 to 10 cm., we reach the sciatic nerve " (Hecht). When the nerve 
is touched the patient feels a sharp pain in the heel or low down 
in the back of the leg, and usually gives an involuntary jerk to 
the leg. In inserting the needle it is usually better to keep the 
stylet within the needle, withdrawing it from the point while 
penetrating the skin, but pushing it in advance of the point again 
as soon as the skin is passed, in order to prevent the sharp needle- 
point from injuring the underlying tissues. The needle should, of 
course, be 8 to 12 cm. long and the syringe contain at least 30 c.c. 
of the solution. The injections may be repeated in twenty-four to 
seventy-two hours, if needed. 

For these injections the patient must lie flat on his abdomen in 
as comfortable a position as possible, with his legs fully extended. 

A similar technic is, of course, used for neuralgia in other loca- 
tions, with the variations made necessary by the anatomy of the 
part. Magnesium sulphate and many other drugs have been used, 
but all without such general success as to render the procedure 
standard. 

We should mention in this connection the anesthesia produced 
by infiltrating the tissues of the anus and rectum by sterile water 
(Gant). This is a blocking of the nerve trunk by tension rather 
than by the chemical action of the solution upon the cells. Its 
success explains why extensive operations (such as herniotomy) 
are successfully performed after infiltrating the tissues to be in- 
cised with solutions too weak in their content of eucain to be ef- 
fective through their direct chemical action. In this category 
comes the use of 0.5-per-cent solution of quinin and urea, now so 
popular for infiltration anesthesia. 

Hence, it is possible for us to relieve pain by blocking the trans- 
mitting fibers, (a) by injecting simple sterile solutions in sufficient 
quantity to distend the tissues; (6) by rapid vibratory massage 
with an electrically driven apparatus; (c) by applying consid- 
erable heat or cold, and finally, (d) by injecting a drug of the 
tropin series for its chemical effect. 

For deadening the sensorium, morphin is the typical drug. 
Morphin is better than crude opium, because the local effects of 
the latter on the stomach and intestines are avoided, as well as the 



PAIN 19 

secondary effects due to the presence of the other opium alkaloids. 
Morphin affects primarily the higher centers of the central nervous 
system by a slight primary stimulation followed by a depression, 
especially of the powers of perception. The effect on the medulla 
is more stimulant and less depressant, especially for the heart beat. 
The respiratory reflexes are, however, decidedly weakened, so that 
coughing is checked and the rate of respiration reduced. This 
removal of the influence of the hemispheres is sometimes desirable, 
and in nervous patients frequently the heart beats more steadily 
and the respiration is more normal after a dose of morphin than 
before. Its effect on the perception of pain alone is frequently 
demonstrated when patients accustomed to the drugs describe their 
sensations. They say, for instance, that the pain does not cease — 
they can feel it — but they can bear it. Morphin does not damage 
the heart muscle, and therefore can be used for quieting pain even 
in heart disorders. It is given hypodermically in £ to \ grain, 
ordinarily in the form of the sulphate. The effect appears in from 
ten to thirty minutes, and with patients unaccustomed to the drug 
leads to sleep. When given by the mouth, morphin is liable to 
cause nausea, and is slower of effect. To overcome this nausea 
(due to the secretion of morphin into the stomach), atropin is 
added in doses of jfe to -g-fo grain. This is done, also, even when 
the drug is given subcutaneously, because atropin acts as a check 
on the medullary effect of morphin, and thus prevents too great 
a stimulation of the inhibitory mechanism controlling the circu- 
latory and respiratory apparatus. Doses of morphin may be re- 
peated in from four to eight hours, but usually smaller doses than 
the initial dose are sufficient to keep up the effect. 

Technic op Hypodermic Medication 

The mention of the subcutaneous administration of morphin 
leads us to discuss at this point the technic of Hypodermic Medi- 
cation. 

There are three types of hypodermic syringes on the market: 
(1), all glass; (2), all metal; (3), glass and metal. The all-glass 
syringes are best because they can be the most thoroughly steril- 
ized. The difficulty in using them consists simply in their liability 
to break. The best all-glass syringe is probably that made by the 



20 SYMPTOMATIC THERAPEUTICS 

Hahnhart Company, Zurich, Switzerland. A similar one, but 
made in pieces, is put out by Burroughs, Wellcome & Company, 
London. Only those all-metal syringes are valuable which have 
no rubber packing around the piston, and in which the piston 
is carefully ground to fit the barrel. The danger in the use of 
these is that they rust when they are not used every day. There 
are various types on the market, but in purchasing a syringe one 
should very carefully test the joints oneself. In the mixed type 
of syringe there is the constant trouble from the drying up of the 
packings, and one must expect his syringe to be useless if he is 
not using it frequently. No matter which type of syringe is pur- 
chased, it should be cleansed immediately after use, and the most 
satisfactory cleansing is probably that in which first water and 
then alcohol is run through the syringe several times. This not 
only cleanses the syringe, but also renders it less liable to rust. 
(Of course, alcohol shrinks the packings, consequently this is not 
very well adapted to the mixed type of syringe.) 

The needles may be had in either steel, platinum, or gold plate. 
The difficulty with the steel needle is that the lumen rusts shut. 
When one must inject corrosive material, such as mercury, it is 
best to have either the platinum or the gold needle. A needle 
should be cleansed in alcohol immediately after using, and when 
put back into its case a piece of wire should be left in the bore. 
This will prevent, as nearly as possible, its rusting shut. 

Just before using, the syringe, with the needles attached, should 
be thoroughly rinsed in hot water. One should draw up hot water 
into the syringe and expel it, repeating this several times before 
putting in the medicated solution. If this precaution be ob- 
served, practically no abscesses will be found from hypodermic 
medication. In this connection, it should be remembered that most 
hypodermic tablets are insoluble in alcohol, and therefore the pres- 
ence of a slight trace of alcohol in the syringe or in the needle will 
greatly hinder the solution. 

The injection may be subcutaneous, or intramuscular, or intra- 
venous. In the first case, the skin on some part of the body where 
there is considerable subcutaneous fat is pinched up between the 
thumb and forefinger of the left hand and the needle inserted 
into this fold parallel to the surface of the body. The contents of 
the syringe are slowly expelled underneath the skin and the needle 



PAIN 21 

quickly withdrawn. The clean finger tip is placed over the point 
of injection until the tissues have taken up the fluid. Intramus- 
cular injection is usually made over the larger and coarser muscles. 
Thus the gluteal muscles are the favorites. In this case the needle 
should be plunged straight inward through the subcutaneous fat. 
Therefore the physician should carefully estimate the thickness of 
this fat in choosing his needles and making the injections. Intra- 
venous injections may be made in the manner of venesections by 
putting the ligature around the arm and pushing the loaded needle 
into one of the distended veins and allowing the fluid to flow in 
drop by drop after the ligature has been removed. Of course, in 
this latter case, the syringe should be pointed in the direction of 
the blood current. 

In all these injections the skin overlying the point of injection 
should be cleansed with hot water and soap, followed by alcohol, 
before the needle is brought into use. 

The effect of intravenous injection is seen almost immediately. 
That of intramuscular varies according to the absorbability of the 
drug used. Thus adrenalin chlorid will give a very prompt effect, 
while the gray oil of mercury or atoxyl, would not be seen for 
some hours. The subcutaneous injection, unless a vein happen to 
be pierced, is the slowest of the three. 

Should there be some pain accompanying the injection, a cloth 
wrung out in hot water should be applied for several minutes. 

It is important in using the syringe and needle to avoid forc- 
ing air into the tissues with the drug. In subcutaneous injections, 
where the needle is to be inserted already attached to the syringe, 
the air is removed by holding the syringe vertically, with the needle 
pointing upward, and pressing on the piston until drops of the solu- 
tion come out of the needle point. In intramuscular injections it is 
necessary to attach the syringe to the needle (which, of course, is 
already in the tissues) firmly, and then, by withdrawing the piston 
slightly, cause the air to bubble up through the solution to the 
piston end of the syringe, and finally, when pressing the piston 
home, to avoid driving the air back into the needle. In intra- 
venous injections the air should be removed as for subcutaneous 
ones, and the additional precaution taken of inserting the needle 
with the solution practically flowing from its point. 



22 SYMPTOMATIC THERAPEUTICS 

Other Drugs 

The coal-tar derivatives are also very generally used to quiet 
pain. They are best adapted for the relief of neuralgias and head- 
aches — that is, pain of nervous origin. These drugs all depress 
the heart, and in heavy doses produce methemoglobin. Hence, they 
should be used with even greater caution than morphin, for, be- 
sides the habit-forming danger common to both, they are apt to 
lower very materially the resistance of the patient to the toxins 
of the underlying disease. Of the coal-tar products, phenacetin 
(acetphenetidin), antipyrin, and acetanilid are the ones generally 
chosen to quiet pain; the others of the series display more promi- 
nently the antiseptic and toxic effects. Of these, antipyrin is the 
most soluble, acetphenetidin the least so. The latter is also the least 
toxic. The dosage varies from 25 to 50 centigrams (0.025 — 0.5 = 3 
to 10 grs.). In order to neutralize the depressant action of these 
drugs, when giving them for nerve pains, sodium bicarbonate is 
usually combined with them. The following, for instance, is a 
conventional combination for nerve sedation, especially headache: 

Acetanilid 0.25 (gr. iij) ; 

Camphor monobromated 0.15 (gr. ij) ; 

Sodium bicarbonate 0.10 (gr. jss.). 

Mix and make one tablet. 

One of these tablets might be given with safety every two hours 
for the ordinary patient, yet I have seen the coal-tar cyanosis ap- 
pear with two doses of a similar combination. This, of course, was 
due to the personal susceptibility ; but this is always to be watched 
for. Acetphenetidin, because of its lesser toxicity, is more often 
given alone than acetanilid for the purpose of stopping a headache. 
It is usually given in five-grain powders or tablets, to be repeated, 
if needed, in two hours. 

In this connection it should be noticed that the salicylates, the 
phenolates, the creosotes, and other coal-tar derivatives all have 
analgesic properties — a fact that makes them all the more useful 
in septic and rheumatic disorders accompanied by severe pain. 

To illustrate these principles, let us enumerate some of the con- 
ditions in which pain is a prominent symptom, and discuss its 



PAIN 23 

treatment. Thus, in arteriosclerosis we often meet the retrosternal 
pain when the patient is active. The first part of the treatment is 
causal; the patient is put to bed and the strain on the arteries 
removed. Then, since the pains are due to spasm of the blood 
vessels, we can adopt the plan of releasing the spasm by the appli- 
cation of heat, and we order hot cloths (moist) applied — to be 
changed every three to five minutes. This usually is sufficient. 
If, at the beginning of our treatment, we should give T ^g- grain of 
nitroglycerin by the mouth or subcutaneously, we secure a quicker 
effect to the relaxing treatment, and the effect of the nitrite would 
be disappearing just about the time when that of the heat was 
beginning. 

Again, in severe pains of acute nephritis, we find local treat- 
ment extremely helpful. Ortner mentions as the first treatment re- 
vulsives applied to the lumbar region, that is, cups, leeches, or 
actual cautery to Petit 's triangle. The cupping is done once or 
twice a day, leeches are applied every other day, and the actual 
cautery usually only once. The ice bag is also recommended. The 
purpose of all this is to relieve the congestion in and about the kid- 
neys. This same result may be secured by venesection of the dorsal 
vein of the foot to the extent of ten ounces. Probably the majority 
of us would differ with Ortner and prefer to use drugs and relieve 
the pain by giving atropin d-j^-) and morphin (£) subcutane- 
ously. The lactate of calcium is a somewhat more causal treatment 
for the relief of this pain : ten grains four times a day. The 
atropin, however, relieves the pain by its local effect on the kid- 
ney and is, therefore, well worth trying. 

The pain of pleuro-pneumonia should be relieved by limiting 
the excursion of the ribs — that is, by bandaging the thorax tightly 
with adhesive plaster. If the pain still continues, morphin should 
be given. 

The pain of cancer of the stomach receives local treatment when 
we give bismuth subnitrate or tincture of belladonna. Usually, 
however, in this condition morphin is needed sooner or later to 
give relief. 

The pain of congestion of the liver is best relieved by produc- 
ing a local hyperemia. For this hot and cold fomentations, the 
thermophore, and similar measures may be employed. 

The pain of tuberculosis of the larynx can be relieved by the 



24 SYMPTOMATIC THERAPEUTICS 

inhalation of ethereal oils. We use chiefly the oil of eucalyptus 
vaporized in water, because the steam of itself seems to have a 
sedative effect. If guaiacol and olive oil, in equal parts, be rubbed 
on the outside of the neck, their effect will also be analgesic. 

The pain of a bruise would be subjected first to the application 
of heat, and, if that did not succeed, to the subcutaneous injection 
of morphin. 

The pain of dysmenorrhea also demands a word, for our teach- 
ing has been that this is a symptom rather than a disease. But 
we should probably admit that Herman's contention (British 
Medical Journal for April 17, 1909) is correct when he maintains 
that there is a genuine dysmenorrhea which should be distin- 
guished from the pains at the menstrual season in cases of sys- 
temic weakness or of local pelvic disease. Real dysmenorrhea 
consists of morbidly painful uterine contractions accompanying 
menstruation. Such pains begin with the menstrual flow. From 
these, therefore, we must carefully distinguish the discomfort due 
to the pelvic congestion of the menstrual season — the sense of 
heaviness and weight in the pelvis. We must differentiate them 
also from the cramplike pain preceding the flow and usually at- 
tributed to ovarian disorders. Furthermore, we must remember 
that any nervous disorder is liable to be made worse by the strain 
of the menstrual season. 

When now we remember that only about one third of our 
women menstruate without pain, we realize that the family phy- 
sician must find a large share of his practice in the symptomatic 
or causal treatment of menstrual disorders. But, on the other 
hand, we should not be led thereby to magnify the condition. On 
the contrary, the psychical treatment that leads our patients to 
bear pain with equanimity and to focus their attention on the 
good points of their physiques rather than their weak ones, will do 
much toward eliminating their dysmenorrheas. Hence, although 
we should endeavor to learn the cause of the painful menstruation, 
this should be done in such a way that the woman's attention is 
not concentrated on the disorder. The emphasis should be on 
hygienic living rather than on local treatments or operative in- 
terference. If we can do this, we shall find that our patients will 
be the better and stronger for it. 

The positive indications call for either raising the nervous re- 



PAIN 25 

sistance to pain and discomfort or decreasing the amount of nerv- 
ous strain endured by the patient. Thus, in some cases we need 
to prescribe tonics, out-of-door life, and hydrotherapy; in others, 
longer hours of sleep, more rational diet, less arduous employ- 
ment. Each patient's life must be studied in order to remove the 
factors for overstrain, and to add those making for health and 
vigor. 

For relief at the menstrual season the coal-tar analgesics are 
usually employed. It is best to employ them sparingly, both on 
account of the liability to habit formation and their tendency to 
free the patient from a feeling of necessity for improving her inter- 
menstrual regimen. Acetphenetidin may be given in five-grain 
tablets, or acetanilid (three grains) and sodium bicarbonate (two 
grains), combined to make a tablet or powder. With many pa- 
tients atropin in y^-grain doses will prove almost specific in 
giving relief. Whenever it does so, it should be chosen in prefer- 
ence to the coal-tar products. Morphin should be used only as a 
last resort, and then only in sufficient quantity to benumb the pain, 
not to put the patient to sleep. 

Membranous dysmenorrhea is proving to be a misnomer be- 
cause investigation is showing that many women who menstruate 
painlessly discharge the membrane in chunks. Hence, we should 
not immediately curette the uterus of such a patient unless we 
find other evidence of an endometritis that demands curettement. 

Probably the best treatment for genuine dysmenorrhea is dila- 
tion of the cervix. This frequently brings about a cure after the 
first trial. Sometimes it is necessary to repeat it once or twice. 
Better than dilation is pregnancy; but inasmuch as this is inap- 
plicable in a large percentage of our cases we must content our- 
selves with the palliative treatment. 

Thus, in general, we seek to use in each case the analgesic which 
has the least systemic effect, and only when that fails do we resort 
to morphin or other systemic narcotics. 

Finally, general anesthesia may be thought of as the symp- 
tomatic treatment of pain ; but since it is a distinct branch of the 
medical curriculum we treat it but cursorily here. In general, we 
may say that the members of the series of the hydrocarbons are 
all narcotic and are effective in proportion to their volatility. 
Practically, we use ether and chloroform for the more severe opera- 



26 SYMPTOMATIC THERAPEUTICS 

tions and nitrous oxid or ethyl chlorid for the minor ones. When 
we wish to secure full relaxation of the patient, even if it be for a 
minor operation, such as hemorrhoidectomy or setting a broken 
bone, ether or chloroform is necessary. Ether is the less danger- 
ous to the heart, but the more irritant to the air passages. Hence, 
we prefer ether, even if it be slower and more irritant, for we can 
overcome the bad effects of these qualities by giving morphin (J) 
and atropin (y-J-y) one quarter hour before the administration of 
the anesthetic. It is best given by the drop method — just as chloro- 
form is given. We prefer the chloroform for relieving the pains 
of childbirth and those of accidents and emergencies where haste 
is essential. 

The administration of anesthetics is an art by itself, and should 
not be attempted without special instruction and an appren- 
ticeship. 

II. FEVER 

Probably the shortest definition of fever is that it is the reac- 
tion of the body to insult. By this we mean that the elevation in 
temperature may of itself be Nature's defense against injury; or, 
again, it may be only a by-product, so to speak, of that defense. 
This insult may be the absorption of foreign bodies or toxins — the 
bruising of flesh, the attack of microbes, or anything that inter- 
feres with the smooth running of the body's machinery. Thus, the 
fever due to the absorption of bruised tissue is simply a chemical 
result of the breaking up and washing out of the body of these waste 
products. Such a fever is harmless. But the fever due to the 
action of toxins on nerve centers is bad in that it is the index of 
the struggle between the toxins and our body cells. 

This theory may be contrasted with that of Avicenna (980- 
1037), who said: " Febris est calor extraneus accensus in corde et 
procedens ab eo mediantibus spiritu et sanguine per arterias et 
venas in totem corpus, ' ' in that we look upon the fever as the effort 
of the body to free itself from the poison or condition, rather than 
(as he did) as the poison or condition itself. The physician's atti- 
tude is very different in the two cases : Avicenna would make direct 
effort to lower the temperature; we would try rather to free the 
body of the poison or material that caused the temperature to rise, 
and thus secure a return to normal by the removal of the cause of 



FEVER 27 

the fever. (See McCallum in the Archives for Internal Medicine 
for January, 1909, and Sollmann's " Therapeutics," p. 350.) 

The increased temperature may be due either (1) to an increase 
in the combustion of the tissues — as in the case of intense muscular 
effort — or it may be due to (2) a blocking up of the channels 
through which the heat is normally dissipated. Thus, to cover 
the body with a coat of varnish would raise its temperature. To 
surround the body with a moist medium, warmer than the body, 
would also cause the temperature to rise. The reason is this: that 
since the glands of the skin dissipate much heat through perspira- 
tion we have a retention of heat leading to fever whenever the 
secreting glands cease to act. 

The two terms — fever and increased temperature — are not, 
however, exactly synonomous. But, like most words, they are not 
always used in their strict sense, and are therefore often used in- 
terchangeably. In general, fever always presents' an increase in 
temperature, but all increases in temperature are not fever. Fever 
is a pathological increase in temperature. But this word is often 
used still more technically — that is, because most of the infective 
and septic diseases have fever as the most prominent symptom, 
therefore the whole disease is often spoken of as the " fever." 
Strictly speaking, however, the fever is but one of the symptoms of 
the inflammation. Its treatment, therefore, is the treatment of a 
symptom and not of a disease itself. 

Fever of itself may or may not be dangerous, according to the 
condition and age of the patient. Thus the infant and child bear 
the increased temperature easily, while the white-haired grand- 
father would be in danger of death, simply because his body can 
no longer accommodate itself to such great changes. A robust man 
may bear with impunity a temperature which would exhaust all 
the strength of a feeble woman. Again, an alcoholic would be 
much sicker than his temperate neighbor with the same tempera- 
ture. Finally, we find personal idiosyncrasies which make our 
patient more or less resistant to the hyperpyrexia. 

In fever, the increased temperature is generally due to the in- 
creased formation of heat, the first of the causes mentioned above, 
and indicates an increase in the rate of tissue consumption or 
waste. Hence, in the treatment of fever we must decide whether 
we shall get rid of this high temperature by depressing the vital 



28 SYMPTOMATIC THERAPEUTICS 

centers concerned in regulating heat production, or whether we 
shall simply increase the heat dissipation, and thus get rid of 
it before it injures the body. The weight of opinion now seems to 
be that it is unwise to check this heat production (i. e., depress the 
heat centers) except where we feel positive that it is injuring the 
patient, or where the cause is evidently so transient that the de- 
pression used to combat the temperature will not be sufficient to 
overcome the patient's resistance to the underlying disease. In 
making such a statement we must remember that it goes without 
saying that the doctor should always seek to rid the body of the 
cause of the increased temperature. For instance, if it be the in- 
vasion of germs, the physician strives to inhibit their growth; if 
it be the absorption of toxins from the bowels, he seeks to cleanse 
the bowels of their putrefying contents; if it be the absorption of 
iodoform from the dressings of a wound, to remove the dressing 
and apply a different sort; or if the cause be of the second type, 
such as an impermeable skin, to soak it and cleanse it in hot water 
until the glands become active, and so on. 

But in many cases we either cannot find the irritant or cannot 
remove it. In such cases, symptomatic treatment is indicated. 
But such an indication holds good only as a temporary meas- 
ure — until the cause is found and removed. In self-limited dis- 
eases too many physicians content themselves with stimulating the 
body of the patient to perform its normal functions — that is, with 
the correction of the symptoms due to the underlying disease, and 
do not make any active attack upon the cause of the trouble. This 
naturally is a hazardous procedure and should never be followed 
when the physician can do anything to discover and remove the 
cause. 

On the other hand, it is not wise to give one's whole attention 
to causal therapy and none to making the patient comfortable ; but 
rather the wise physician is the one who keeps both methods in 
mind. 

The easiest way of increasing the dissipation of heat is, for in- 
stance, by the application of cold water to the body. The most 
radical method of giving the cold bath is to dip the patient in a 
tub of cold water at about 60° P. This is a great shock to the 
system and can be endured only by robust people. On the capil- 
laries and glands of the skin it causes first a contraction, followed 



FEVER 29 

shortly by an expansion, with an increased excretion of water 
vapor. This latter process, of course, rids the body of much heat 
energy. In case of typhoid fever, such a bath (called there the 
Brand bath) reduces the temperature from one to three degrees. 
In giving the bath, one should be careful to keep the patient in the 




Fig. 2. — Portable Bath Tub for the Sickroom. 

water only a minute or two, and should take pains to give a thor- 
ough rub immediately afterwards. The bath may be given accord- 
ing to the following method: The patient is lifted out of bed on 
a strong sheet held by two or more nurses, and let down into the 
water; the nurse strokes the patient gently with the palms of the 
hands while he is in the water. Then the patient is lifted out 
again and laid on a rubber blanket, dried off under flannel, and 
returned to bed. 

For those patients who cannot withstand the shock of these 
plunges into cold water, cold sponging may be used. In prepara- 
tion for this, flannel blankets are placed both above and below the 
patient. The water is made ready at 60° to 70° F. and kept stead- 
ily at that temperature by the addition of ice. Only one part of 
the body is wet at a time, and this is dried off with towels before 
proceeding to the next part. To be effective, the sponging must 
be slow and steady — the whole operation demanding an hour for 
completion. Besides reducing the temperature, this sponging seems 
to stimulate the mind and give the patient a refreshing feeling of 
well-being. 

In cases of inflammation of the brain and spinal cord, it is bet- 
ter to apply the cold locally. Thus, ice packs are placed about the 
head and along the spine. The packs are best made by filling 



30 



SYMPTOMATIC THERAPEUTICS 



large-mouthed rubber bags with cracked ice. These bags are made 

in special shapes to fit the various parts of the body. The rubber 

should not come in contact with 

the skin, but should be covered 

with a towel or napkin. The 

water from the melted ice should 

be removed as soon as it is 





Fig. 3. — Ice Bag for Spine. 



Fig. 4. — Flat Ice Bag. 



formed, in order to keep the temperature of the ice bag uniform. 
When the rubber bags are not available, ice packs or poultices may 
be made by mixing sawdust and 
cracked ice and wrapping the 
mixture in oilcloth and towels. 

This local application of cold 
is also used in heart disease 
and peritonitis, and, in general, 
wherever it is desired to inhibit 
the processes of localized inflam- 
mation. 

Another local application of 

cold for dissipating heat and 

causing local vascular contraction _, 

Fig. 5. — Leiter Coil for Flat Sur 
may be made with the cold-water faces, such as the Chest. 





Fig. 6. — Leiter Coil for the Head. 



(Leiter) coil. This is made by winding four or five yards of J-inch 
tubing into shape to fit the part of the body affected. One end 



FEVER 31 

is placed in a vessel of ice water above the level of the patient's 
body, and the other end in a vessel on the floor and the water 
passed through the tube by siphon action. When the upper vessel 
is empty, it is replaced by the lower one ; and the process continued 
without needing additional water. The only necessity is the ad- 
dition of fresh ice. 

Sometimes a high temperature may be reduced by setting up 
vigorous diaphoresis — either by the use of -J grain (0.02 gm.) of 
pilocarpin hypodermically or by a hot pack. The latter is made 
by placing a rubber blanket both above and below the patient and 
then tucking in about the patient a sheet wrung out of hot water. 
This sheet needs to be renewed every three to five minutes, and 
should be renewed without exposing the patient to the cold air of 
the room. This is accomplished by slipping the fresh sheet in 
under the cooled one and the overlying flannel blanket. Such an 
application of heat must be kept up for an hour to set up sufficient 
diaphoresis to accomplish results worth while. Needless to say, the 
indications for using the sweating pack for reducing the tempera- 
ture in fever are rare. It is indicated rather in acute intoxications, 
collapse conditions, etc. 

The second method of reducing temperature is by preventing 
the formation of heat — that is, by depressing the " heat centers." 

This depression is accomplished chiefly by drugs, and of these 
the coal-tar antipyretics hold the first rank. They act largely by 
the lessening of heat production, although with some there is a 
flushing of the skin leading to an increased dissipation. Most of 
these drugs are plasmodial poisons, and therefore decrease the 
rapidity of metabolic processes (i.e., the production of heat), but 
their first and most noticeable effects are the depression of the cen- 
tral nervous system. The heart is also depressed and the blood it- 
self attacked. Hence, these drugs are to be used with caution, and 
rarely in cases where there is heart weakness or danger of collapse. 
Thus, to give them in pneumonia, typhoid fever, and diphtheria, 
where a fatal issue is liable to occur because of toxemia (i. e., of 
the depression of the nerve centers by the toxins of the disease 
themselves), would be unwise. They are best adapted for use in 
short and ephemeral fevers, where there is little danger of a long 
and prostrating confinement. 

Of the coal-tar antipyretics, the best and least toxic seems to be 



32 SYMPTOMATIC THERAPEUTICS 

phenaeetin (acetphenetidin) . This may be used in doses from 0.3 
to 1 gm. (5 to 15 grains), as a powder or in capsules. It is so in- 
soluble that it does not work up well in liquid preparations. Next 
comes acetanilid, more toxic but more soluble. With this a dose 
of 0.5 gm. (7-J gr.) should rarely be exceeded. In fact, it is better 
to give acetanilid with some antagonistic drug to overcome its 
depressant action. Thus, a dose made up of: 

Acetanilid 0.2 gm. (3 gr.) ; 

Sodium bicarbonate 0.2 gm. (3 gr.) ; 

Camphor monobromated 0.1 gm. (1J gr.), 

makes a relatively efficient and safe combination for quieting the 
nervousness and reducing the temperature of a fever patient. 

Antipyrin is the third important antipyretic, recommended by 
its solubility, but possessed of greater toxicity than the other two. 
Because of its solubility, its action is more rapid. The dose varies 
from 0.25 to 1 gm. (3 to 15 gr.). 

Quinin has an analogous action, but its toxic effect on muscle 
tissue makes it unsafe as an antipyretic. 

In peritonitis and phthisis, good effects may be obtained from 
an inunction with liquid guaiacol. Fifteen drops of this with an 
equal amount of olive oil rubbed into the abdomen reduce the tem- 
perature quite markedly. Its effect is also analgesic. Hence, it is 
very useful where we wish to save the stomach from distressing 
drugs. Since the guaiacol is so readily absorbed, and since it is 
so antiseptic, it should always be thought of in septicemic condi- 
tions, when a reduction of the temperature is desirable. 

The vegetable remedies, aconite and gelseminum, are so slow 
and unreliable that they have given place to the above prepara- 
tions in fever. They are apparently just as dangerous, if not more 
so, than the coal-tar derivatives. In other words, they offer no 
advantage over these, and may therefore be omitted from the 
armamentarium. 

With some physicians one drop of the tincture of aconite given 
hourly at the beginning of acute fevers seems to have proven 
of value — probably more because of its relaxing effect on the 
nervous mechanism than because of any temperature reduction 
obtained. 



FEVER 33 

Calcium sulphid (Calx sulphurata) has been put forward by 
some American missionaries in Turkey (Van) as a cure for typhus, 
smallpox, scarlatina, and similar fevers. The profession has used 
this drug spasmodically for years, but it seems never to have been 
able to obtain a permanent place in our armamentarium. Its dose 
is 1 grain (0.065 gram) three to six times a day, until the system is 
saturated — as is shown by the odor of hydrogen sulphid exuding 
from skin and breath. One should be careful to watch for en- 
teritis when using the drug, because of its tendency to irritate the 
bowel mucosa. Probably some of its good effects are due to the 
calcium rather than the sulphid — since lime is proving to have a 
decided influence on the condition of the body fluids, as is shown by 
the work of Bell and Hick in Liverpool (British Medical Journal, 
February 23, 1909). 

The question of diet in fever is also an important one. The 
history of medicine shows periods when starvation was urged in all 
cases, and, again, other periods of time when high feeding was in 
vogue. The ideal is, of course, to give the patient the greatest 
amount of nourishment consistent with obtaining a good influence 
on the course of the disease. For if feeding the patient with a 
strong diet raises his temperature or prolongs the course of his 
fever, it would be better to feed more lightly. Therefore, in fevers 
having their seat in the intestinal tract it is generally wise to use 
nonfermenting, nonirritating food, and that in only such a quan- 
tity as shall be easily cared for by the digestive glands. / 

Tissue consumption in fever is greater than in health. Hence, 
if we endeavor to prevent the loss of weight and maintain our 
patients in equilibrium, we must give much more than the 33 cal- 
ories of heat energy per kilogram of body weight that is required 
for the healthy adult at rest. In fact, the amount needs to be be- 
tween 50 and 60 calories per kilo. 

For typhoid fever Shaffer and Coleman have shown, that by 
giving 60 to 90 calories of food energy daily, consisting chiefly 
of carbohydrates, the patient's equilibrium can be maintained 
(Archives for Internal Medicine, December 15, 1909). Whether 
the course of the disease is not lengthened thereby and the net 
gain therefore very small remains to be seen. 

A good rule to follow is to give all the food the patient can com- 
fortably take and to make it consist chiefly of the fuel-giving foods 



34 



SYMPTOMATIC THERAPEUTICS 



in an easily digested form. Thus we prefer to give milk, cream, 
eggs, oven-dried toast (or triscuit) rather than beef extracts and 
broths. We give the food at three-hour intervals, and thus avoid 
weighing down the stomach with either quantity or variety. 



III. ITCHING 

Itching may be due to some constitutional disorder, such as 
diabetes mellitus or jaundice, or it may be due to local irritation, 
such as the presence of living parasites or chemical irritants. 
Hence, one should always try to ascertain its cause, even if its tem- 
porary relief be easy. In order to epitomize the possible causes of 
itching, I give here the following table from Bulkley. The 
causes are : 



1. External 



2. Idiopathic 



Parasitic 



i 



TMicrobic 
-j Vegetable 
[Animal 
f Mechanical 



Miscellaneous J Toxic 

[Climatic 



f Senile 
1 Neurotic 



[ Autotoxic 
3. Constitutional J 



fReflex 
^Functional 
f Acute 
1 Chronic 



I Dermato-pathologic 

Even symptomatic treatment would necessitate a differential 
diagnosis between the external and constitutional causes, because 
there are two possible lines of treatment, namely: (a) local and 
(b) internal. Local treatment means the soothing of irritated 
nerves, and should therefore be employed only when the sensory 
nerves in the skin are really irritated. On the other hand, internal 
treatment, which means a depression of the nerve centers to pre- 
vent reflexes and the transmission of the uncomfortable sensation, 
should be employed only when these reflexes are exaggerated or 
the psyche is abnormally excited. We would repeat, then, that 
symptomatic treatment cannot be successfully followed out until 
some conclusion as to the cause of the trouble has been reached. 



ITCHING 35 

The most frequent form of itching is that due to the presence 
of parasites, and here causal treatment can be successfully com- 
bined with the symptomatic. Thus, an ointment that will soften 
the epidermis and kill the parasites can also soothe the irritated 
nerves. In fact, the three requirements of any local application 
for itching due to the presence of parasites would be : 

(a) Ability to penetrate (or soften), the epidermis; 

(6) Ability to kill the parasite and its ova or larvae; and 

(c) Ability to quiet the nerve irritation. 

Such local treatment means practically the application of an 
ointment or of an alcoholic or glycerin solution. When the skin 
is dry and scaly, the ointment, excluding as it does the air, is the 
usual choice; when the skin is moist or greasy, the alcohol or 
glycerin does better. The base of an ointment, to penetrate the 
skin, should be wool fat (adeps lanae), and where this is too fluid, 
paraffin and wax may be added. Of course, the drug chosen for 
the different parasites varies. Thus, for scabies, one usually 
prefers either mercury or sulphur; for pediculi, mercury or 
naphthol (epicarine) ; for vegetable organisms (e.g., barber's 
itch), thymol or guaiacol. The best drug for softening the epi- 
dermis is salicylic acid. The most sedative drugs are menthol, 
camphor, atropin, phenol, etc. One then might write for ring- 
worm or other eruption due to a vegetable organism the following 
prescription : 

Acidi salicylici 5.0 grams. 

Mentholis 2.0 " 

Adipis lanse q. s. ad 30.0 ' ' 

M. f. ung. Sig. Rub into eruption and bandage overnight. 

The pharmacopeial sulphur ointment that we might use for 
scabies consists of fifteen per cent sulphur in eighty-five per cent 
of benzoinated lard. The sulphur softens the epidermis as well 
as kills the louse, while the benzoin keeps the lard from becoming 
rancid. 

The mercurial ointment that we might use for the same pur- 
pose contains about fifty per cent of mercury and is prepared as 
follows : 



36 SYMPTOMATIC THERAPEUTICS 

Mercury 500.0 grams. 

Oleate of mercury 20.0 ' ' 

Prepared suet 230.0 " 

Benzoinated lard 250.0 ' ' 

1,000.0 " 

When this is weakened by the addition of a third part of pe- 
trolatum, we have the blue ointment (ung. hydrargyri dilutum), 
which is therefore about thirty per cent of mercury. It is more 
often used than the stronger ointment given above. 

A rather more modern mercurial ointment for parasitic dis- 
orders is the ung. hydrargyri ammoniati, made up as follows : 

Ammoniated mercury 10.0 grams. 

White petrolatum 50.0 " 

Hydrous wool fat 40.0 " 

100.0 " 

In this we have a better base and a more active form of the mer- 
cury. Hence, the fact that it contains less mercury does not make 
it any less useful than the other mercurial ointments. 

Of the coal-tar series it is naphthol that seems most successful 
as a parasiticide and sedative. Of the naphthol derivatives 
epicarine is now enjoying the greatest popularity. One could pre- 
scribe it in the formula last given by substituting it for ammoni- 
ated mercury. This has the advantage of being somewhat more 
cleanly than the mercurials. 

Besides the above we find among the standard ointments the 
following, called variously the Itch Ointment of Hebra, Wilkin- 
son's salve, and the ung. sulphuris compositum, N. F. : * 

Calcium carbonate 10.0 grams. 

Sublimed sulphur 15.0 ' ' 

Oil of cade 15.0 " 

Soft soap 30.0 " 

Lard 30.0 " 

This is more irritant than the others and would not do for delicate 
skins or sensitive people. 

1 The abbreviations N. F. and U. S. P. refer to the National Formulary and 
United States Pharmacopeia respectively. 



ITCHING 37 

Still one other formula deserves our attention. This is the ung. 
resorcini co., N. F. : 

Resorcinol 6.0 grams. 

Zinc oxid 6.0 " 

Bismuth subnitrate 6.0 " 

Oil of cade 12.0 " 

Paraffin 10.0 " 

Petrolatum 25.0 " 

Lanolin (wool fat) 35.0 " 

Here we have the sedative effects of zinc oxid and bismuth sub- 
nitrate, the antiseptic effects of resorcinol, and the stimulant effects 
of the oil of cade. It is, therefore, a general ointment of weaker 
parasitical power, but more sedative than the sulphur or mercury. 
Its power of penetrating the stratum corneum is also less. It is, 
however, an ointment which, with slight variations, is being sold 
under different copyrighted names directly to the public, and for 
all sorts of skin diseases. 

When we wish to avoid the grease and dirt of ointments, we 
make use of alcoholic preparations because they are quickly ab- 
sorbed and leave no telltale evidences on the skin. We use them, 
therefore, in the disorders due to less resistant parasites and where 
the patients are in position to apply them frequently. A sample 
prescription is the following : 

Thymolis 5.0 grams. 

Methylis salicylatis 10.0 ' ' 

Phenolis 5.0 " 

Alcoholis 

Glycerini aa 40.0 ' ' 

Sig. Apply every hour until relieved. 

In the types of itching due to mechanical, chemical, or thermal 
irritants there is often a watery exudate. This makes desirable 
another form of treatment; that is, something that will keep the 
surface dry and at the same time soothe irritated nerve ends. For 
this a powder is desirable. The base of such powders is usually 
absorbent enough to take up the excess moisture and firm enough 



38 SYMPTOMATIC THERAPEUTICS 

to form a protecting crust when combined with such moisture. 
For sedative purposes zinc oxid is the favorite addition, because it 
is both astringent and sedative. For antiseptic purposes a great 
variety of drugs are in use, as iodoform, bismuth subgallate, ace- 
tanilid, boric acid (very weak), the camphors, etc. 

For instance, a powder made up as follows would be both seda- 
tive and antiseptic: 

Acidi salicylici 10.0 grams. 

Camphorag 5.0 " 

Amyli 40.0 " 

Talci purificati 45.0 



i i 



Most of the so-called talcum powders on the general market de- 
pend upon boric acid for their antiseptic qualities. Hence, they 
are too weak for our use, and, besides, are usually not sterile when 
compounded. 

For special purposes we should make prescriptions for suitable 
powders rather than try to have a stock powder for all purposes. 
Thus, for the condylomata lata of syphilis we should need the pres- 
ence of calomel, and we might write for the following powder: 

Hydrargyri chloridi mitis 20.0 grams. 

Acetanilidi 20.0 " 

Amyli 30.0 " 

Talci purificati 30.0 " 

Sig. Dusting powder for condylomata. 

For the distress attendant upon ivy poisoning, we might pre- 
scribe : 

Zinci oxidi 20.0 grams. 

Acidi tannici 10.0 ' ' 

Mentholis 5.0 " 

Talci purificati 65.0 " 

Sig. Dusting powder for weeping eczema. 

And, in general, we should endeavor to use the drug that will 
give the special sort of relief called for. We might even find occa- 



ITCHING 



39 



sion to employ the soluble antiseptic powder of the National For- 
mulary, which is made up as follows : 



Salicylic acid 

Phenol (U. S. P.) ... 
Eucalyptol (U. S. P.) 
Menthol (U. S. P.) . 
Thymol (U. S. P.) 

Zinc sulf 

Boric acid, in impalpable powder 



5.0 grams. 
1.0 



1.0 

1.0 

1.0 

125.0 

866.0 



This, as can be seen, would be astringent, antiseptic, and seda- 
tive to the surface applied, and if mixed with equal parts of talc or 
starch would do for dusting over wounds and abrasions. Where 
the skin is not broken it could be used in full strength. 

The relief of the idiopathic itching, due as it is to senile and 
other tissue changes, is more difficult because the causes are not 
so easily removed. Hence, while we can quite easily afford tem- 
porary relief, the treatment must be kept up so long and so con- 
tinuously that many patients grow tired and go from doctor to 
doctor and from drug store to healer, always with the same un- 
satisfactory result. These alterations in the skin can perhaps best 
be influenced by the internal or hypodermic use of arsenic com- 
bined with massage. The diet and exercise of the patients need 
also to be carefully regulated, to the end that all these factors 
work toward a more active nutrition of the skin through an in- 
creased flow of blood as well as increased activity of the cutaneous 
glands. 

The local relief is obtained usually by means of weak ointments 
— ointments just strong enough to soothe the tissues, but not as 
strong as would be needed for parasiticidal action as was needed in 
the ointments we have been describing. The base is best made of 
wool fat and the active ingredients of thymol and menthol. Some- 
times it is necessary to add carbolic acid and similar more powerful 
drugs, but they are liable to do quite as much injury as good. In 
such cases the unguentum resorcini compositum, N. F., given above, 
affords a good general formula. For the ordinary cases the local 
application of the following should be sufficient for temporary 
relief : 



40 SYMPTOMATIC THERAPEUTICS 

Bismuth subnitrate 5.0 grams. 

Thymol .'. 3.0 

Menthol 5.0 

Zinc oxid 10.0 

Wool fat 40.0 

White petrolatum sufficient to make . . . 100.0 

Perhaps the most troublesome form of senile itching is the 
pruritus vulvae vel ani. For this one needs to use more stimulant 
applications than elsewhere, although in many cases the formula 
just given would prove sufficient. Here the addition of tincture 
of belladonna or atropin will, often afford the element of relief, 
lacking in the more locally acting ingredients. One might even 
use an oil compounded somewhat as follows : 

Ung. belladonnas (U. S. P.) 15.0 grams. 

Olei gaultherias 5.0 ' ' 

Glycerini 10.0 " 

Olei olivas 10.0 " 

Sig. Apply with finger or cotton only as needed for relief. 

In the neurotic type of itching it is the systemic treatment upon 
which we must depend for effect. Here the bromids, to reduce 
the reflex irritability, will be most often called for. In addition, 
of course, the causes of nervous excitement to be found in life and 
environment must be removed (causal treatment). For temporary 
relief hot baths, massage, oil inunctions, etc., will render much 
better service than the topical application of ointments. To par- 
ticularize: The bromids would be given in doses of fifteen grains, 
three times a day, in dilute solution, thus: 

^ Sodii bromidi 20.0 grams. 

Tct. belladonnas 10.0 " 

Glycerini 40.0 " 

Aquas destill q. s. ad 100.0 " 

Sig. One teaspoonful in a half glass of water, three times a day. 

We would prescribe the hot baths at a temperature of 100° to 
110° for fifteen minutes every day for three or four days, then 



INSOMNIA 41 

gradually decrease their frequency. Each should be followed by 
a friction rub and rest in bed for an hour or two. 

Sometimes the hot-air cabinet, or the electric-light cabinet, on 
alternate days, continued until the forehead has perspired for at 
least eight minutes, and followed by gentle friction, would prove 
even more effective than the tub bath. It should be followed by 
sponging in cool water and rest in bed, as with the tub bath. 

When we discuss the constitutional causes, we should not for- 
get to mention the diseases of which itching is a direct symptom. 
Thus it may be the only symptom vigorous enough to call the 
patient's attention to his condition in diabetes mellitus. Itching 
also usually accompanies jaundice. Lead poisoning, alcoholism, 
and gout are accompanied by itching. Various nervous diseases, 
particularly lesions of the cord, are accompanied by itching, and 
formication is a symptom of cocain poisoning and pelvic disturb- 
ances, as well as of the other diseases just enumerated. Hence, in 
these troubles all that we need to do is offer temporary relief and 
depend for the cure upon the removal of the underlying lesion. 
For this purpose the application of camphor water, witch hazel, 
and similar mild sedative astringents may prove entirely sufficient. 
These aqueous solutions require frequent application, and where 
that is impracticable it is wise to prescribe a mild ointment like the 
following : 

^ Thymolis 
Mentholis 

Phenolis aa 2.0 grams. 

Paraffini 10.0 " 

Adipis lange q. s. ad 30.0 ' ' 

In autotoxemia itching is frequently a vigorous symptom. 
Here active catharsis, sweat baths, and diet constitute the causal 
treatment. The symptomatic is practically that just outlined for 
the other forms of constitutional disease. 



IV. INSOMNIA 

Sleeplessness may find its cause in the (1) pain the patient is 
suffering from in some intracranial disease or lesion, (2) in the 



42 SYMPTOMATIC THERAPEUTICS 

lack of need of sleep, (3) in some psychic disturbance, or (4) in 
a general nervous exaltation. Thus, after an accident or injury 
the patient does not sleep because the pain of the wound prevents 
his mind from reaching the stage of quiet necessary for sleep. 
Again, if one overslept the preceding night, or has a nap in the 
afternoon, one is hardly apt to fall easily into slumber at night. 
Similarly, a patient on the sick bed who dozes much during the 
day is apt to have wakeful nights irrespective of his being com- 
fortable and contented in every other respect. Again, mania or 
other psychic disturbance has what is perhaps its most charac- 
teristic and distressing symptom in the inability of the patient to 
sleep. Not until the sleeplessness is conquered can the physician in 
charge hope to treat the underlying causes. And even when there is 
no specific mental disturbance, there may be such an exuberance of 
spirits, such a joy of living present, that the patient cannot sleep. 

Physiologically, the condition of sleep is one of relative cerebral 
anemia. Whether or not the individual neurones are out of con- 
tact with each other during sleep may still remain an unsettled 
theory, as far as our methods of treatment are concerned, because 
the anemia is sufficient to explain the phenomena of sleep and is 
also sufficient as a goal toward which to aim. 

Considered physiologically, as distinguished from the clinical 
study mentioned above, the causes of insomnia may be mentioned 
as follows: 

1. Disturbance of the nerve reflexes. 

(a) From within, as from intense thought or excitement. 

(b) From without, as from noises, bright lights, disturb- 

ing odors, etc. 

2. Congestion of the brain from some disturbance of the cir- 

culation. 

3. Intracranial pressure, as from a tumor, or hydrocephalus, or 

a disturbance of the equilibrium of the cerebrospinal fluid. 
* 

Granting the above analysis to be approximately correct, the 
aim of our therapy would then be : 

1. To put the mind out of contact with the outside world. 

2. To reduce the amount of blood circulating in the brain. 

3. To cause the body's vegetative machinery to run smoothly. 



INSOMNIA 43 

The first of these could be obtained by making the sick-room 
quiet and dark, preventing unnecessary disturbance from passers- 
by, and the entrance of the odors from the kitchen, etc. The sec- 
ond is sometimes brought about by such a simple procedure as 
giving the patient a light lunch ; the consequent gastric hyperemia 
is naturally accompanied by a corresponding, anemia of the brain. 
A similar effect is sometimes obtained by giving a hot foot bath. 
The third requirement calls for a regulation of the respiration, 
circulation, digestion, and excretion of the patient. For it goes 
without saying that sound sleep is impossible if the body's machin- 
ery goes by fits and jerks. 

The treatment above outlined would in a general way be spoken 
of as etiologic, but it is nevertheless so schematic as to be con- 
sidered somewhat symptomatic. The real symptomatic treatment 
of insomnia, however, simply goes to work to depress the whole 
upper part of the central nervous system. An ideal drug would 
depress the higher centers without affecting the lower. Hence, 
the ideal hypnotic is a drug that shows its effect on the nervous sys- 
tem, beginning with the higher and working downward toward the 
lower functions. In other words, thought, will, and judgment are 
rendered difficult and slow, while the spinal reflexes and the breath- 
ing and the cardiac action are hardly touched by such hypnotics. 

The standard hypnotic, because it affects the nervous system 
from above downward, still remains chloral hydrate, although con- 
stant effort is being made to improve it so as to secure the hypnosis 
without endangering the heart or the vital nerve centers. Chloral 
should be given in doses of 1 to 3 gm. (15 to 45 gr.) in dilute solu- 
tion. It is best given an hour or two before bedtime, and the 
vehicle should be chosen for its ability to overcome the nauseating 
effects of the drug. Hot milk, the digestive mixtures, and even 
water, are useful for the solution. A prescription might be made 
up as follows: 

^ Chlorali hydrati 5.0 grams. 

Ext. fl. cascaras sag 1.0 " 

Tct. gentian co 5.0 " 

Glycerini 25.0 " 

Aquae 15.0 " 

Sig. One dessertspoonful in water two hours before bedtime. 



44 SYMPTOMATIC THERAPEUTICS 

It may be given by the rectum, but is irritant to the mucosa (hence, 
it must be in very dilute solution), and should be in slightly 
greater dosage than when given per os. The dose should not be 
repeated within two hours at least. 

When the lower centers are the seat of some excitement — when 
general nervousness is the cause of the insomnia — sodium or potas- 
sium bromid is a better drug than chloral. This should be given 
in similar dosage and in similar form to the chloral. This, for in- 
stance, is the drug to choose in the insomnia of heart disease. Hot 
milk also offers a good vehicle for the bromids. The sodium salt 
should be used unless one wishes to secure the katabolic effect of 
the potassium ion. It should always be remembered that long-con- 
tinued use of bromids may produce bromism, a condition charac- 
terized by skin eruptions and a foul breath. 

The synthetic hypnotics, planned to take the place of chloral, 
follow apparently one of three lines : the line of effect produced by 
the use of urea, that of the ethyl derivatives, or, finally, that of 
chloral. Of the first group veronal is the best example. This 
is given in capsules or hot milk. The dose varies from 0.3 to 1 
gm. (5 to 15 gr.). The drug seems to be fairly effective. 

Of the second group trional offers the best results. This 
is usually given as a powder in a dosage of 1 gm. (15 gr.). Toxic 
effects have been met with, but they are rare. 

Of the third group dormiol may be used as an example. This 
is a combination of chloral and amylene hydrate. It is not pleasant 
to take and is therefore given in syrup. Fifteen cubic centimeters 
(J oz.) of a ten-per-cent solution should be used. 

Another useful hypnotic is tromural. This represents an effort 
to combine the effects of valerian, bromides, and urea. The drug 
is therefore best adapted to hysterical types of insomnia. It is 
put out in five-grain tablets, which should be swallowed whole. If 
the patient cannot take a tablet, the drug should be given in a hot 
solution. Ten grains (0.6 gm.) seems to be the minimum effective 
dose for hypnosis. 

Chloretone is an acetone chloroform and seems effective in 
cases of simple nervousness. One gram (15 gr.) is necessary for 
effect. 

Hyoscin may be used hypodermically Cr^ to -gV gr. — 0.001 to 
0.002 gm. — of the hydrobromid) for cases of mania and similar 



CONSTIPATION 45 

troubles. It is somewhat uncertain in its effects, but when com- 
bined with morphin is quite uniform in quieting the patient. This 
combination should be used cautiously when there is any lesion 
of the nervous apparatus controlling respiration, because even in 
the normal individual the rate of respiration is sometimes reduced 
by it even to five or six in the minute. Its special indication, there- 
fore, appears in cases of general nervousness, such as those follow- 
ing emotional shock and worry. The effect of one dose of \ grain 
of morphin and yjhj- grain of hyoscin may last from four to 
eight hours. 

In every case of insomnia much help is to be obtained from 
mental suggestion and the quieting influence of the physician's re- 
assuring words and acts. If the physician show that he is sure 
of himself and his methods, that he is in command of the situation, 
the amount of depressing drugs needed will be greatly reduced. 
"With these patients, therefore, the physician should never be 
brusque or sharp. He must take the time to sit down by his pa- 
tient and by his very quietness and placidity influence the patient 
toward self-control. Sometimes such influence is helped by light 
massage ; probably as much by the touch of a sympathetic hand as 
by the mechanical effect of the stroking movement. 

V. CONSTIPATION 

Constipation is such a general complaint among our patients 
that it is worth while to spend a moment in investigating its char- 
acter and causation. Since we find it more prevalent among the 
leisured classes than among those who lead an active out-of-door 
life, we must conclude that the cause of the trouble lies in the 
habits of life rather than in inherent weaknesses. For the poor, those 
who eat coarse foods and who work long hours, are most subject 
to disorders due to extraneous influences, and yet suffer less from 
constipation than their wealthier neighbors. Indeed, we reach a 
similar conclusion when we look at the matter from the a priori 
standpoint, for we know that our bodies are what they are because 
they have proven to be the most fit to meet the conditions of life 
imposed upon them by our environment; that is, our bodies have 
been slowly following the changes in environment. Now, our en- 
vironment has greatly changed in the last millennium, for whereas 



46 SYMPTOMATIC THERAPEUTICS 

our ancestors in the forests of Europe lived in rude huts, with 
little or no protection against the changes of weather, and with the 
roughest of food — lived a life that compelled them to be very 
active and rugged — we live in overheated houses, are protected 
from every extra exertion, and eat foods that are not only well 
masticated for us, but are also partly predigested. Hence, where 
our ancestors needed long intestines to work over and store up 
quantities of tough and weakly nutritious food, we need hardly 
any more than is sufficient to absorb the highly concentrated nour- 
ishment that is put within them. Moreover, our ancestors ate at 
long intervals and great quantities; we, however, eat frequently, 
though, alas ! often also in too great quantity. The extra room for 
storage is not needed in our mode of life. But this extra room 
renders the excretion of the unused portion of our food material 
slower and more difficult, both because of the lack of stimulus 
which was found in the old days in the rough nature of the food 
ingested, and also because of the unnecessary distance through 
which the waste portion must pass. The excitation of the digestive 
fluids by the reflexes from the act of mastication is also lacking, 
because we do not masticate our food as our ancestors had to do, 
and the exhortation to such mastication of food that almost melts 
in the mouth presents such an illogical proposition that it is rarely 
heeded. 

The conditions found in cases of constipation may be summar- 
ized, for the sake of convenience, in three classes, viz.: (1) spasm, 
(2) paralysis, and (3) atony. 

Sometimes we find that normal defecation is prevented by a 
nervous contraction of the intestinal walls so great as to prevent 
the natural propulsion onward of the food masses. This may be 
due to reflexes from some ulcer or abraded or inflamed surface 
either in the mucosa of the intestine or in the serosa of .the peri- 
toneum, or it may be due to a general nervous exaltation. At any 
rate, the condition is one wherein the nerve plexuses of the intes- 
tinal wall are in a state of tonic spasm — a spasm that must be 
broken up if normal peristalsis is to result. We find such a spasm 
in case of pericolitis, hernia incarcerata, prolapse of the bowel, 
intussusception, etc. Hence, the search for the cause must consider 
many and varied possibilities. 

The second type is quite the opposite, for here there is a lack 



CONSTIPATION 47 

of " nerve tone." There is not the normal response of peristalsis 
to the stimuli given by the presence of food and bowel secretions. 
This may be due to a general nervous flaccidity or to a relaxation 
of blood vessels and musculature in the splanchnic area. This is 
the type found among sedentary people and those who eat much 
and exercise little. 

The third type is found among invalids and weaklings. It 
is a condition of weakness on the part of the muscle rather 
than of the nerves. It may result from the paralysis of the in- 
testinal tract, or from the use of predigested foods, or in any 
way that leads to idleness or nonuse of the intestinal muscles and 
glands. 

From the above, it is easily seen that the causal treatment of 
chronic constipation calls for a building up of the musculature of 
the whole abdominal area, both of the muscles of the abdominal 
walls and those of the intestines and the walls of the blood vessels 
also. This means, of course, the increased use of these muscles 
either by means of special exercises or by massage. The exercises 
best adapted to this are the bending exercises detailed in books on 
medical gynecology and similar works. The most important move- 
ments are: (1) Lying on the back and raising the legs to the ver- 
tical, both singly and together; (2) standing and bending forward 
and touching the floor with the finger tips while both knees are 
kept stiff, and then bending backward with the arms over the 
head; (3) standing with the hands on the hips and twisting the 
shoulders to an angle with the hips; (4) standing between two 
chairs and ' ' dipping ' ' with the hands on the backs and then rais- 
ing oneself until the arms are straight again; (5) chinning oneself 
by pulling oneself up to a door lintel or other crossbar. 

Besides working on the musculature in the above way, one 
should seek to develop normal peristalsis by the use of appropriate 
foods, selected drugs, and externally by massage. The foods best 
adapted to stimulating peristalsis are the bulky vegetable foods. 
For instance, a colleague of mine is very partial to popcorn and 
sweet potatoes for this purpose. Cauliflower, lettuce, corn on the 
cob, peas, beans, cabbage, etc., may all be used for the same pur- 
pose. For similar reasons cooked fruits and sauces are helpful in 
that they afford some chemical stimulus to the peristalsis. Of 
these, apples and prunes seem to have the best reputation. 
5 



48 



SYMPTOMATIC THERAPEUTICS 



Externally, also, one can accomplish much by massaging the 
abdomen. One generally uses heavy pressure with the flat hand — 
the one supporting the other — and moves his hands in the direc- 
tion of the hands of a clock, considering the abdomen as the clock 
face, beginning at the caecum and following the course of the colon. 




Fig. 7. — Massage of the Colon for Constipation. 



This should be done in the morning in order that it may conform 
to the normal time of defecation. The patient, of course, lies on 
his back on a rather firm couch or table. 

Sometimes this massage may be done by oneself by employing 
a heavy ball or other round object. Thus, one can get a six-pound 
cannon ball and cover it with a flannel cover in order not to chill 
or irritate the skin, and roll it about the abdomen in the same way 
that the massage is given. 

Among the drugs that promote the evacuation of the bowels 
we observe two general types : those that serve for temporary use 
and those adapted to chronic cases. Thus, in the first class we find 
calomel, mineral salts, and castor oil. In the second class we find 
cascara, ox gall, colocynth, phenolphthalein, etc. Prom the first 
class we select calomel when there is fermentation or putrefaction 
present, or when we seek to put the emphasis of our work on the 



CONSTIPATION 49 

upper part of the bowel. We can use castor oil when we desire 
a sweeping out, as it were, of the upper bowel, without any stimu- 
lation of secretion or other glandular action, because castor oil 
excites peristalsis in the small intestine by means of its chemical 
irritation. Ox gall sets up an active peristalsis when injected into 
the colon. It seems to have no peristaltic effect on the small 
bowel. The mineral salts are best used when it is desired to flush 
the bowel and secure a watery stool. They effect the result both 
by means of chemical irritation and by the withdrawal of fluid 
from the tissues by endosmosis. The most effective of the cathartic 
salts is sodium sulphate (Glauber's salts). It has also the most dis- 
agreeable taste. Magnesium sulphate (Epsom salts) is changed 
into sodium sulphate by the action of the contents of the bowel. 
Consequently, its action is probably that of the sodium sulphate. 
But since its taste is pleasanter it is usually preferred to the lat- 
ter. Rochelle salts (potassii et sodii tartras) is slightly pleasanter 
to take, but rather weak in its action. All salts are most effective 
when given in concentrated (i. e., hypertonic) solution, though, of 
course, such concentration makes them more bitter to the taste. 
This bad taste is sometimes alleviated by giving the salt dissolved 
in a very small quantity of hot water and following it up immedi- 
ately with a bit of syrup, glycerin, or similar pleasant-tasting sub- 
stance. For immediate catharsis these salts are most effective 
when given on an empty stomach. The dosage of all of them 
ranges upward from one half ounce for the adult. 

These salts form the basis of most of the cathartic mineral 
waters. Hence, mineral waters are frequently nothing more than 
cathartic salts prepared in a pleasanter form than that of the ordi- 
nary artificial salt. For instance, the Carlsbad Sprudel spring 
water shows the following composition (in grains in the liter) : 

Sodium chlorid 15.45 

Sodium carbonate 20.415 

Sodium sulphate 35.58 

Calcium carbonate 4.455 

with traces of other salts of strontium, iron, manganese, silica, etc. 
Another, an American water, the Veronica, shows the following 
composition (in parts per million) : 



50 SYMPTOMATIC THERAPEUTICS 

Ammonium chlorid 0.24 

Potassium chlorid 169.50 

Sodium chlorid 3,170.00 

Sodium sulphate 802.70 

Magnesium sulphate 15,151.40 

Sodium nitrate (NaN0 3 ) 744.30 

Calcium bicarbonate 1,397.80 

Iron and aluminum oxid 3.70 

Silica 18.10 

The nauseating taste of castor oil is overcome when one floats 
the dose (-J to 1 oz.) on coffee, or adds a few drops of lemon juice 
to it. Its cathartic effect should be obtained in one or two hours. 
The saline cathartics require about the same time, while cascara 
requires from eight to twelve hours. Phenolphthalein requires at 
least four hours for effect. For these reasons castor oil and the 
saline cathartics are generally chosen when one seeks the prompt 
evacuation of the bowel, and phenolphthalein and cascara when an 
overnight cathartic is desired. 

For chronic conditions, on the other hand, the mineral salts 
are rarely given, but cascara sagrada and similar vegetable cathar- 
tics are chosen instead. As a general principle, one should not con- 
fine oneself to one drug, but should change from one to another 
in order to prevent the development of an immunity. Thus, the 
giving of fifteen drops of fluid extract of cascara for a fortnight 
should be succeeded by a like period of phenolphthalein in one- to 
two-grain doses. And so on. Whatever the drug used, catharsis 
is promoted by drinking much water on an empty stomach, as 
at bedtime (one to two glasses), on rising, and between meals 
(e. g., ten glasses pro die). Of course, periods of mineral-water 
drinking may be interspersed between periods devoted to other 
drugs. 

The symptomatic treatment, when considered for itself, with- 
out thought of the subsequent developments of constipation, calls 
simply for the immediate and thorough evacuation of the intestine. 
This, therefore, may be accomplished in its simplest form by using 
enemata to soften the masses or scybala lying in the colon, and to 
wash them out; and by giving castor oil or saline cathartics to 
carry down the masses from the upper intestine. 



CONSTIPATION 51 

Enemata. — This leads us to a consideration of various solutions 
used for enemata. The first principle is to use a solution that will 
not harm the bowel. For unless the enema agree in chemical re- 
action with the contained fluids it is liable to injure the mucosa. 
The gentlest of enemata is that with the normal saline solution. 
This does not irritate the bowel and rarely excites even the peri- 
stalsis. It simply dissolves and washes out the material lying 
within reach of the solution. Naturally, therefore, it must be used 
in greater quantity than more stimulating solutions, two or three 
quarts being a minimum quantity. 

The next more vigorous solution is glycerin. This may be given 
in the strength of one part of glycerin to eight parts of water. Fol- 
lowing glycerin in strength come solutions of ox gall and the 
cathartic salts. These may be used in varying dilution, according 
to the amount of water it is desirable to use. This in turn depends 
on whether a solution of the fecal masses is desired or whether the 
stimulation of the peristalsis is the chief object sought. This in 
turn depends on whether one uses a long or short rectal tube. 

The ordinary " rectal " tube is 19 inches long, while the 
" colon " tube measures 30 inches. The former is used when it 
will suffice to put the solution into the ampulla recti, or at most 
into the sigmoid flexure. The latter must be used if one desires to 
put the solution above the sigmoid flexure. To accomplish the lat- 
ter feat, the patient must lie on the left side with the knees drawn 
up, with the abdomen as relaxed as possible. The tube is thor- 
oughly oiled with vaselin or olive oil and inserted with a turning 
motion. As soon as it meets an obstruction, the solution is turned 
on with the irrigator or bag two feet above the level of the anus, 
and the pushing forward of the tube, with the turning motion (to 
prevent the tube from bending on itself), continued. The force 
of the flowing solution usually forces the intestinal walls, as well 
as the fecal masses, out of the way so that the flexure is finally 
passed. 

From the above, it will be seen that large quantities of 
water must be at hand for high colonic flushing; that is, when 
washing out rather than stimulation is sought. In such cases the 
solution is much more dilute, say one ounce each of ox gall and 
sodium sulphate to the quart, than when the short tube is used. 
In the latter case the solution should contain at least two ounces 



52 SYMPTOMATIC THERAPEUTICS 

of each ingredient to the quart. This same principle applies also 
when we use the other ingredients — glycerin, soapsuds, etc. 
In summarizing the above discussion we may note : 

(1) To empty the bowels we give castor oil, calomel, or saline 
cathartics, preferably with an enema to soften the hard masses 
lying in the colon. 

(2) To overcome tonic spasm of the bowel we use atropin. 

(3) To overcome flaccidity we use strychnin or similar vaso- 
motor stimulant. 

(4) To combat habitual constipation we use the slower-acting 
cathartics, such as phenolphthalein, cascara, podophyllin, etc., but 
lay the emphasis on correcting the mode of life that has brought 
on the condition, and finally 

(5) When everything else fails we can resort to a surgical op- 
eration (Lane) to " short-circuit " the bowel and rid the patient 
of some of the long passage leading up to the stasis. 1 



VI. VOMITING 

Quite frequently we find it necessary to produce vomiting in 
order to empty the stomach hurriedly, and again we find occasion 
to check vomiting. Hence, a brief study of the conditions govern- 
ing this symptom will be profitable. Put briefly, vomiting is due 
to a spasmodic contraction of the abdominal muscles (including 
the diaphragm) with or without a coincident contraction of the 
stomach itself. These contractions may be brought about by irri- 
tation within the intestinal tract itself, by psychic influences, and 
by reflexes from other parts of the body. Hence, manifold influ- 
ences may excite vomiting, and we can rarely exclude the psychic 
influences. 

To excite vomiting the layman sticks his finger down his throat. 
The old Romans and our predecessors of the Middle Ages followed 
up the principle somewhat further and used feathers and elongated 
glove fingers to produce the same result. Other laymen use mus- 
tard water or some other nauseous compound. We may follow 
their example ; or may use drugs definitely affecting the vomiting 
center of the medulla. Thus, a subcutaneous injection of T V grain 

1 For the details of this operation, see Binnie, " Operative Surgery," vol. i. 



VOMITING 53 

of apomorphin will within a very few minutes produce a complete 
evacuation of the stomach. Or syrup of ipecac (one teaspoonful 
for children) effects the same result, in somewhat longer time, 
when taken internally. The apomorphin acts centrally, ipecac acts 
locally, or practically as the crude mustard water or sulphate 
preparations do. Hence, in the great majority of cases, apomor- 
phin is the preferable drug. It should therefore always be present 
in the physician's emergency equipment. It should, of course, 
always be used with the hypodermic needle. 

To quiet vomiting is usually not easy. If the cause be peri- 
toneal irritation, the frequent washing out of the stomach with 
the stomach tube is probably the best procedure. For this 
pure water is as good as any solution, and little or none should 
be left inside the viscus. If the cause be a reflex from a loaded 
colon and other results of constipation, castor oil in coffee, 1 fol- 
lowed by ox-gall enemata, will be found quite efficient. If the 
cause is pregnancy, nerve sedatives should be used, and when these 
fail and there is danger of death from a continuance of the vomit- 
ing the uterus must be emptied. Of such sedatives the bromids 
and atropin are the types. The bromids are to be chosen when 
there is no local irritation and the atropin where there is such irri- 
tation. When the vomiting is due to ulcers and erosions in the 
stomach and duodenum, atropin and bismuth are the drug types. 
The atropin inhibits the sensory nerves and the bismuth forms a 
coating over the lesion. The vomiting from gall-bladder disease 
and appendicitis is partly due to peritoneal disturbance and partly 
to the more local reflexes, hence gastric lavage accompanied by 
nerve sedation is called for when there is no opportunity to pro- 
ceed directly against the underlying lesion. It is usually unwise to 
use morphin in such cases, because it obscures the picture. Vomit- 
ing, due to reflexes from the olfactory center or psychic influences, 
is best treated by causal treatment accompanied by psychothera- 
peutic procedures, such as a change of the environment and a sooth- 
ing of the mind. The vomiting of seasickness is best relieved by the 
recumbent posture, closing the eyes, and keeping the stomach 

1 Castor oil excites the peristalsis in the small intestine only, ox gall excites a 
similar movement in the colon. Thus, the two are necessary for complete evac- 
uation of the tract. 



54 SYMPTOMATIC THERAPEUTICS 

empty. The vomiting after anesthesia is often relieved by laying 
ice-cold cloths over the throat, moistening the lips with vinegar, 
and the use of the ice bag over the epigastrium. The swallowing 
of cracked ice assists in keeping the patient comfortable in all 
those conditions where the local conditions do not forbid its use. 

In using bismuth subnitrate for vomiting, better results will 
be obtained if large doses suspended in water be employed. Thus, 
a teaspoonful of bismuth subnitrate floated in one half glass of 
water will be more effective than a five-grain tablet followed by a 
little water. 

The bromids should, of course, be used in solution. The vehicle 
should be carminative, such as the so-called essence of pepsin, com- 
pound tincture of gentian, etc., both taken well diluted. The dose 
of the bromids is 15 grains. It may be necessary to give the bromids 
by the rectum in order to secure the bromid effect without the ac- 
companying danger of gastric irritation ; in this case they should be 
used in doses varying from 20 to 30 grains in 2 to 4 ounces of water. 

Atropin fortunately can be used hypodermically, and one could 
use doses of -gV grain in that way. But in order to secure the local 
effect on the gastric mucosa, it would be better to use the tincture 
of belladonna — ten drops in a dessertspoonful or more of water. 
The tincture may be given again in two hours if needed. 

VII. HICCOUGH 

Another distressing and obstinate symptom is hiccough. This 
may be due to peritoneal irritation, and as such is a very unfavor- 
able sign as to the condition of the patient. On the other hand, hic- 
cough may be a reflex from the sympathetic nerve centers, or may 
indicate nothing more than hysteria. 

For its quieting we would best proceed to diminish the activity 
of the reflex arcs; that is, use general rather than local treatment. 
For this purpose the bromids and atropin are the typical drugs. In 
fact, the two may be combined as in the following prescription: 

Tct. belladonnas 2.5 grams. 

Sodii bromidi 5.0 " 

Tct. gentiame co 10.0 " 

Aquas q. s. ad 20.0 " 

Sig. One teaspoonful every two hours if needed. 



COUGH 55 

For the local treatment of the stomach, when we believe that 
the cause lies therein, we might use cocain, tincture of belladonna, 
or bismuth subnitrate. It is best, of course, to use the belladonna 
and bismuth and reserve the cocain to the last emergency. Both 
these drugs should be used as directed in our discussion of vomit- 
ing. That is, the tincture of belladonna should be used in ten-drop 
doses every hour or two until relieved. The subnitrate of bismuth, 
to be effective, would have to be used in at least ten-grain doses. 
The cocain could be used in doses varying from one twelfth to one 
quarter grain; the action of this drug is so evanescent as to be al- 
most useless except for introducing some other drug. It is usually 
best to have the bismuth in ten-grain powders at hand and sus- 
pend it in water (and add, if necessary, the belladonna) extem- 
poraneously rather than try to secure a permanent mixture of such 
incompatible drugs. 

VIII. COUGH 

Cough is Nature's response to some irritation in and about the 
respiratory passages; the irritation may be in the mucous mem- 
brane itself, or conveyed to the same center from the irritation of 
neighboring nerves. For instance, cases have been known wherein 
irritation in the external auditory canal, or the cavum tympani 
was found to be the cause of a persistent ringing, hollow cough. 
Similarly, irritation in the mucous membrane of the upper gastro- 
intestinal tract has been sufficient to excite the cough center and 
produce an uncomfortable hacking cough instead of vomiting, as 
one would naturally expect. Usually, however, the irritation is in 
the mucosa somewhere between the naso-pharynx and the alveoli; 
most frequently, perhaps, in the larynx, because that membrane 
seems the most sensitive. 

Before treatment of cough may be begun it is important to as- 
certain whether or not that cough is something necessary to relieve 
the tissues of some irritating or toxic debris, or whether the reflex 
is caused by something not to be removed by coughing. For in- 
stance, if there be an irritating substance on the mucous membrane, 
it would be unwise to stop the cough. On the other hand, if the 
cough be due to an abrasion or ulcer, then the cough is unproduc- 
tive and unprofitable. For this reason, a careful investigation 



56 SYMPTOMATIC THERAPEUTICS 

into the causation of the cough is necessary before we begin even 
symptomatic treatment. 

The symptomatic treatment consists in depressing either the 
nerve endings of the mucous membrane in which the irritation 
starts, or the medullary center that gives rise to the cough 
stimulus. 

The first is accomplished by subjecting the mucous membrane 
to a stream of soothing vapor. Of the substances used for this 
purpose the most effective and the most easily used is steam, either 
alone or medicated. For instance, by pouring a film of turpentine 
or an essential oil over the boiling water one can secure a vapor 
carrying that oil in finely divided form and influence the air pas- 
sages as far down as the bronchioles. To make the inhalation most 
effective it is wise to have some sort of closed cabinet in which the 
steam is generated and inhaled. The cabinet may be of cloth, as 
in the case of the bronchitis tent (q. v.), or an umbrella may be 
raised over the patient's head and the steam allowed to rise under 
it. Or again, a towel or sheet may be thrown over the patient and 
the steaming dish, and the patient in that way secure the benefit 
of the inhalation. 

Next to steam, the most important sedative for cough is the 
oil spray. Of the oil sprays a good type is the chloretone inhalant 
of Parke Davis & Company, which is made up as follows: 

Chloretone 0.1 grams. 

Camphor 2.5 " 

Menthol 2.5 " 

Oil of cinnamon 0.5 ' ' 

Refined liquid petrolatum 93.5 



i i 



This, as every oil for inhalation, must be vaporized by strongly 
compressed air. The hand vaporizers are usually ineffective, as at 
least twenty pounds' pressure is needed for thorough work. Each 
treatment should be continued for ten or fifteen minutes if it would 
be effective. 

For depressing the medullary centers, the best drug is heroin. 
This should be used in doses of ¥ V to J-grain every three hours, 
according to the patient's age, size, and idiosyncrasies. It should 
be remembered that heroin gives a tendency to dizziness, and for 



SHOCK 57 

that reason patients should not move around while taking it. If 
heroin be not at hand, morphin is the next best choice. 

The addition of syrups to make a so-called " cough syrup " is 
a useless punishment of the stomach. 

IX. ASTHMA 

Asthma is essentially the spasmodic contraction of the bronchi- 
oles, thus preventing the normal inspiration and expiration of air. 
In some cases it is due to inflammation of the bronchial membranes. 
In others it is a reflex from various other organ systems, for we 
find descriptions of renal asthma, cardiac asthma, nasal asthma, 
and even hysterical asthma. Hence, asthma is also a symptom that 
demands a search for its source and the institution of vigorous 
causal treatment. 

Asthma is characterized by its paroxysmal occurrence, an ex- 
piratory dyspnea, and acute transient emphysema (Edwards). 
Hence, it must be differentiated from edema or spasm of the glot- 
tis, laryngeal paralysis, or similar causes leading to inspiratory 
dyspnea. 

The relief of the symptom is obtained by the use of atropin to 
overcome the nervous spasm or of the nitrites to stimulate the vaso- 
dilators. The former is given among the laity in the form of the 
fumes from burning dried stramonium or other herb of the atropin 
group. It is better, however, for the physician to give atropin it- 
self subcutaneously. Both nitroglycerin and atropin may be given 
in the first dose, because the former acts sooner than the latter, and 
thus more prompt relief is obtained. In some cases it is necessary 
to depress the medulla by giving morphin (gr. ^). The intramus- 
cular injection of adrenalin also sometimes gives relief. 

The treatment between the attacks consists in building up the 
body as well as removing the special cause of the disorder. For 
this the out-of-door life, the regulation of the diet, hydrotherapy, 
as well as such drugs as arsenic and potassium iodid are employed, 
as we shall learn when we discuss the underlying lesions. 

X. SHOCK 

We shall have occasion to mention shock in various connections, 
so here we need speak only of its symptomatic relief. 



58 SYMPTOMATIC THERAPEUTICS 

The raising of the body temperature and the contraction of the 
blood vessels are the two most effective measures. The first is ac- 
complished by placing bottles filled with hot water about the pa- 
tient's body, taking care that neither glass nor rubber touch the 
skin. At the same time hot drinks should be given the patient. 
The second is accomplished by injecting intravenously ergotoxin or 
some form of nonirritating aseptic ergot subcutaneously, or adre- 
nalin intravenously. The first is used in a dosage of T V grain 
(0.0013 gm.) (Cronyn & Henderson), the second from 1 to 2 c.c, 
and the third in doses of 10 to 25 drops. 

Of course, friction and other means of stimulating the circula- 
tion should not be neglected. Constricting clothing should be re- 
moved. It may even be necessary to start up artificial respiration. 

XI. EMACIATION 

The symptomatic treatment of emaciation is sometimes neces- 
sary. Of course, if one can discover the causes at work and check 
their action one does this as the first duty. But even then some 
direct attack on the condition of the body weight should be made. 
The conditions in which emaciation is a marked feature are con- 
sumption, diabetes, hyperthyroidism, malignant disease, and some 
sorts of gastritis. In consumption the raising of the weight con- 
stitutes practically causal treatment. So, also, in some mental and 
nervous disorders the raising of the body weight is at least coin- 
cident with improvement in the other symptoms. In the other con- 
ditions named, one feels that the whole force of our therapy should 
be directed against the primary causes, and that the patient will 
regain his weight as soon as these causes cease to operate. Bed- 
sides the above well-known and definite conditions there are 
many conditions of general malaise in which we can discover 
nothing more definite than unhappiness and worry. Here the 
body weight is an index of the metabolic processes, and its move- 
ment upward or downward is an index of our success as thera- 
peutists. 

The first condition essential to the putting on of weight is free- 
dom from worry and overwork. In some cases the physician will 
be able by suggestion and education to put his nervous patients 
into greater harmony with their environment. In many, however, 



EMACIATION 59 

he will find it necessary to change the environment. This means, 
in some cases, a visit to health resorts or friends. In others it 
means the Weir-Mitchell treatment in a well-appointed sanitarium 
or hospital. In all cases it demands that the patient become quiet 
and passive and subject to the directions of the physician. Those 
patients who have well-developed religious natures are more easily 
dealt with than the light-minded and frivolous, because they are 
more willing to consider themselves subject to divine will, to fate, 
or to the laws of nature, or whatever term each may have for the 
Infinite. This submission to natural laws rids the body of irritat- 
ing nervous impulses and permits all the bodily machinery to run 
smoothly and efficiently. Such patients sleep better, rest better 
when awake, digest their food better, and eliminate waste products 
better than do their neighbors, who insist on managing for them- 
selves all their affairs, and violating every law, both external and 
temporal, hygienic and moral. This passivity is so important that 
the physician does well to make a definite attempt to bring it about, 
both by example and precept; even hypnosis should be utilized 
when necessary. 

The next element of cure is a good digestion. This demands a 
free movement of the bowels, as well as the digestion and absorp- 
tion of the food taken. Some of this effect is to be obtained by 
drugs, but more by means of careful dieting. The principle gov- 
erning the arrangement of the diet is that a few articles of food in 
frequent meals are more easily cared for than heavy meals and 
greater variety at longer intervals. Thus, a patient will put on 
flesh if given steak, toast, and baked potato three times a day, 
with eggnog twice a day between times. He does so because he 
utilizes a greater percentage of the foodstuff ingested. Of course 
the dietary must not become monotonous, nor should the food 
be served in an unappetizing form or manner. The following 
is Binswanger's modification of Weir-Mitchell's dietary for build- 
ing up the emaciated : 

First Meal, 7 a.m. 

250 gm. (1 tumblerful) boiled milk, or cocoa made with half 
milk and half water. 

2 to 3 triscuits or zwieback. 



60 SYMPTOMATIC THERAPEUTICS 

Second Meal, 9 a.m. 

A cup of bouillon. 

20 g-m. (f oz.) meat. 

30 gm. (1 oz.) of Graham bread or toast. 

10 gm. (J oz.) of butter. 

Third Meal, 11 a.m. 

125 to 175 gm. (4J to 6 oz.) milk, with a tablespoonful of con- 
densed malt or the yolk of an egg. 

Fourth Meal, 1 p.m. 

80 to 100 gm. (2J to 3 J oz.) soup, with oatmeal, barley, or 
rice. 

50 gm. (If oz.) roast beef. 

10 gm. (^ oz.) potatoes. 

7 to 10 gm. (J to J oz.) vegetables. 

20 gm. (f oz.) sweet rice pudding. 

50 gm. (If oz.) compote. 

Fifth Meal, 4 p.m. 

125 gm. (4J oz.) weak tea, cocoa, or malted milk. 
2 triscuits. 

Sixth Meal, 6 p.m. 

20 gm. (f oz.) meat (hot or cold roast, scraped raw meat, 
tongue, ham, etc.). 

10 gm. (-J oz.) Graham bread or toast. 
5 gm. (■£■ oz.) butter. 

Seventh Meal, 8 p.m. 

125 gm. (4-J oz.) soup, cooked with 10 gm. (J oz.) of butter and 
the yolk of an egg, oatmeal, barley, etc. 

Eighth Meal, 9.30 p.m. 
125 gm. (4J oz.) malted milk. 



EMACIATION 61 

The drugs used are the bitter tonics and laxatives. Thus the 
following prescription secures the stimulant effect of strychnin 
and the cathartic action of cascara and glycerin: 

Tct. nucis vomicae 10.0 c.c. 

Flext. cascaras sag 5.0 ' ' 

Glycerini 40.0 " 

Aquae destill 40.0 " 

Sig. One teaspoonful, diluted in water, three times a day. 

In many cases it is necessary to use the more constitutional ef- 
fects of arsenic and mercury. Thus, the old-fashioned x Donovan's 
solution will be found useful as a general tonic in cases of senile 
debility. Again, corrosive sublimate in doses of ¥ V grain will be 
found useful ; of course, particularly so in syphilitic subjects. Prob- 
ably the intramuscular injection of mercury in consumption finds 
its chief value in the stimulus it gives to the entire metabolism. 

The use of hydrotherapy and massage aids greatly in building 
up wasted bodies. Thus, the cold morning bath in the tub or with 
the shower, followed by a vigorous rub, sets the whole circulatory 
system in a healthy glow. Then again a soothing oil rub at bed- 
time puts the patient in condition to enjoy a good night's sleep. 
For the individual disease, special modifications must, of course, 
be made. Thus, the hysterical and neurasthenics will need spinal 
fomentations, salt glows, drip sheets, alternating sprays, etc., to 
stimulate the bodily processes and produce a regular and healthy 
alternation of fatigue and rest. The consumptive and diabetic, on 
the other hand, must be treated very gently. But we shall discuss 
those points under the different diseases. 

The morning cold bath must begin with the patient as the phy- 
sician finds her. If she is used to a daily tub bath, this should be 
continued, but the water should be made one or two degrees cooler 
each day until she can plunge with pleasure into a tub of water at 
70° F. If she is not used to the tub, sponge baths must be used 
at first with the water at 80° F. and gradually cooling it to 60° F. 
When 60° F. is reached, the patient is usually able to begin the 
tub baths at 80° or 85° F. These then should be cooled from day 

1 Donovan's solution is composed of 1 per cent each of the iodides of mer- 
cury and arsenic. It should be given in five-drop doses well diluted in water. 




Fig. 8. — A Portable Tub. 



62 SYMPTOMATIC THERAPEUTICS 

to day until 65° or 70° F. is reached. The tub bath should not last 
more than five minutes and never long enough for the patient 

to become blue or chilly. On 
emerging from the tub the 
patient should be vigorously 
rubbed and kneaded until her 
body glows. She should then 
lie down, and after a rest of 
thirty to forty-five minutes take 
breakfast. 

The evening rub should, on the other hand, be gentle and sooth- 
ing. Friction, with inunction of olive oil in long, slow strokes in 
a warm room, kept up for nearly an hour, should be employed. 
Its success is to be judged by the patient 's sleepiness. The person- 
ality of the nurse has much to do with the success of such treat- 
ments. Hence, the physician must often modify his prescription 
according to the type of nurse available. 

The spinal fomentations and similar invigorating treatments 
should be given during midday, not less than an hour after the 
full (or second) breakfast, nor later than four in the afternoon. 
They should be followed by at least an hour's rest in bed. The 
technic of the spinal fomentations has already been given. That 
of the salt glow is as follows : The initial bath is made up of about 
40 gallons of water, with 6 pounds of sodium chlorid and 8 ounces 
calcium chlorid (or, if in a larger tub, in similar proportions). If 
the course consists of twenty-eight baths, the final bath should be of 
10 pounds and 8 ounces to the 40 gallons. The strength of the min- 
eral content is increased from time to time by the addition of 1 
pound of the sodium chlorid and 1 ounce of the calcium chlorid 
until the above maximum has been reached. The patient is put in 
the tub and the water poured over him and slapped about him until 
the skin is all in a glow. He is then dried off and allowed to rest. 
The drip sheet is described best by saying that the patient is 
shrouded in a sheet and then cold water is thrown over him and 
his sheet-enshrouded body gently slapped. The pouring and slap- 
ping continue until the desired state of stimulation is obtained. 
The temperature of the water and the length of the treatment must 
be suited to the patient's resistance, varying in temperature from 
70° to 50° F. and in length from two to five minutes. 



OBESITY 63 

The alternating douche or spray demands the use of a com- 
plete apparatus by which the temperature of the spray can be in- 
stantly changed from 70° to 110° F., or similar changes as needed. 
Such sprays are given in the form of a fan, needle sprays, or solid 
currents, as the resistance of the patient may demand. 

In general, in neither exercise nor treatment should the patient 
be quite fatigued. On the contrary, we should try to have these 
things make him just pleasantly tired. Hence, as his body weight 
and strength increase, the vigor of exercise and treatment need to 
be proportionately increased, until the patient is able once more 
to meet his daily duties and still maintain his equilibrium. 

XII. OBESITY 

There is a condition that may be properly called pathological 
obesity (adiposa dolorosa), accompanied by backache, shortness 
of breath, and scattered pain. There are also many cases of obes- 
ity where there is no pathological process, but simply the results 
following the ingestion of too much food with too little physical ex- 
ercise. The former type requires, of course, definite and causal treat- 
ment. For the latter simple symptomatic treatment is sufficient. 

The causal treatment of obesity is based on the observation that 
lack of sufficient thyroid secretion tends to the laying on of fat. 
Hence, in pathological obesity we give dried thyroid gland in tab- 
let or powder three times a day in five-grain doses. This should be 
given on an empty stomach and at least one half hour before meals. 

The symptomatic treatment demands first of all an attempt 
to balance the amount of food or energy ingested with the amount 
of energy needed for the work that the patient must do. This 
means, of course, the prescription of less food in one case and more 
exercise in another. In general, it seems more practicable to have 
the patient increase his exercise than to decrease the quantity 
of food. 

Voit and Pettenkofer, of Munich, many years ago determined 
by actual experiment the average amount of energy, measured in 
calories of heat, consumed by male adults in twenty-four hours. 
This proved to be about 3,000 to 3,400 calories. Later researches 
have put the amount somewhat lower, viz., 2,500. To supply this 
energy physiologists advise the consumption of 3 to 4 ounces of 
6 



64 SYMPTOMATIC THERAPEUTICS 

proteid, 17 ounces of carbohydrates, and 2 ounces of fat for an 
average man doing average work. Or, reduced to kilograms (2.2 
lbs.) of body weight, for average work our patients need for each 
kilogram of normal weight 1.7 grams of proteid, 0.8 gram of fat, 
and 7.1 grams of carbohydrate each day. By multiplying the 
weight of our patient expressed in kilograms by these figures we 
secure the amount of each class of food needed by that patient, 
expressed in grams. (To reduce this to ounces we have simply to 
divide by 31.5.) These amounts include the food that is undi- 
gested and passed out through the alimentary canal. This loss is 
estimated at^ in the ordinary mixed diet. The relation between 
calories and grams may be expressed as follows (Ortner), where 
' ' gross ' ' means the total amount ingested and ' ' net ' ' the amount 
absolutely absorbed: 

1 gm. proteid = 4.1 gross calories or 3.2 net calories. 

1 " fat =9.3 " " " 8.4 " 

1 " carbohydrate = 4.1 " " "3.8" 

Of course this relation between net and gross must vary consid- 
erably according to the variety of food used. Thus in meat, flour, 
bread, etc., ten per cent is lost, while in rye bread, vegetables, etc., 
thirteen to seventeen per cent is lost. 

Of late years the matter of energy needed to run the body has 
been studied over again, and it has been found that with some 
attention to the selection of the food and increased care in masti- 
cation, the amount of food needed may be greatly decreased. This 
is the movement calling upon us all to reduce the amount of food 
which was introduced by Horace Fletcher and known as Fletcher- 
ism, and followed up by Professor Chittenden, of Yale. The ques- 
tion, however, narrows down to that of the necessity of what Voit 
called the luxus consumption, the extra amount of food taken 
by most individuals that is not needed by a strict analysis of the 
balance of ingestion and excretion, but which seems necessary to 
protect the organism against accident and disease, or is at least 
so considered by many conservative thinkers. For therapeutic 
purposes it is sufficient to know that most of our patients suffering 
from obesity would do better on 1,500 calories than 2,500 pro die. 

For governmental studies of dietaries the following factors are 
used in calculating meals: 



OBESITY 



65 



Man at hard muscular work requires 1.2 times the food of a man 
at moderately active muscular work. 

Man with light muscular work and boy fifteen to sixteen years 
old require 0.9 the food of a man at moderately active muscular 
work. 

Man at sedentary occupation, woman at moderately active 
work, boy thirteen to fourteen, and girl fifteen to sixteen years old 
require 0.8 the food of a man at moderately active muscular work. 

Woman at light work, boy twelve, and girl thirteen to fourteen 
years old require 0.7 the food of a man at moderately active mus- 
cular work. 

Boy ten to eleven and girl ten to twelve years require 0.6 the 
food of a man at moderately active muscular work. 

Child six to nine years old requires 0.5 the food of a man at 
moderately active muscular work. 

Child two to five years old requires 0.4. 

Child under two years old requires 0.3. 

One other standard of values needs now to be studied, and that 
is the relation of weight to height. The following is the European 
standard (Quetelet) : 



Males. 



Females. 



Age in Years- 



Height 
in — 



Weight 
in kilos. 



Weight 
in lbs. 



Age in Years. 



Height 
in — 



Weight 
in kilos. 



Weight 
in lbs. 





1 
2 
3 
4 
5 
6 
7 
8 
9 

10 
11 
12 
13 
14 
15 
16 
17 
18 
20 
25 
30 
40 



ft. in. 



71 
3 
6 
10 
1 
3 
5 


2 

4* 
6* 
8* 
10§ 
1 

2* 

4 
5 

5§ 

6 
6 
6 



3.20 
9.45 
11.34 
12.47 
14.23 
15.77 
17.24 
19.10 
20.76 
22.65 
24.52 
27.10 
29.80 
34.40 
38.80 
43.60 
49.70 
52.90 
57.90 
60.10 
62.90 
63.70 
63.70 



7.0 

20.7 

24.8 

27.2 

31.2 

34.5 

37.8 

42.0 

48.5 

49.7 

52.8 

59.6 

65.5 

75.6 

85.3 

95.9 

109.3 

116.3 

127.3 

132.3 

138.3 

140.1 

140.1 





1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

12 

13 

14 

15 

16 

17 

18 

20 

25 

30 

40 



in. 

7 

24 

6* 

91 
1 

2* 

7 

9 
10 
10* 

1 

3 

5 

7 

9 

10* 
1 

H 

2 

21 
21 
21 



2.91 
8.79 
10.67 
11.79 
13.00 
14.36 
16.01 
17.54 
19.08 
21.36 
23.52 
25.70 
29.80 
32.90 
36.70 
40.40 
43.60 
47.30 
51.00 
52.30 
53.30 
54.30 
55.20 



6.4 

19.2 

22.3 

25.8 

28.6 

31.5 

35.2 

38.5 

41.8 

46.9 

51.7 

56.5 

65.5 

72.3 

80.7 

88.9 

95.9 

104.0 

112.2 

115.0 

117.2 

119.4 

121.4 



66 



SYMPTOMATIC THERAPEUTICS 



Males. 


Females. 


Age in Years. 


Height 
in — 


Weight 
in kilos. 


Weight 
in lbs. 


Age in Years. 


Height 
in — 


Weight 
in kilos. 


Weight 
in lbs. 


50 


ft. in. 
5 51 
5 4" 
5 3i 


63.50 
62.90 
59.50 


139.7 
138.3 
139.9 


50 

60 


ft. in. 
5 * 
5 
5 


56.20 
54.30 
51.30 


123.6 


60 


119.4 


70 


70 


112.8 







The American standards are the following: 

WEIGHT TABLE (Male) 1 
(Showing average weight for each height and age.) 
Based on "Nylic Graphic Table." Correct to one pound. 



Age. 


57 


58 


59 


60 


61 


62 


63 


64 


65 


66 


67 


68 


69 


70 


71 


72 


73 


Ins. 


Ins. 


Ins. 


Ins. 


Ins. 


Ins. 


Ins. 


Ins. 


Ins. 


Ins. 


Ins. 


Ins. 


Ins. 


Ins. 


Ins. 


Ins. 


Ins. 


20.... 


104 


108 


Ill 


114 


117 


121 


125 


128 


132 


136 


140 


144 


149 


153 


158 


163 


167 


21.... 


105 


108 


111 


115 


118 


122 


125 


129 


133 


137 


141 


145 


150 


154 


159 


164 


168 


22.... 


106 


109 


112 


116 


119 


123 


126 


130 


134 


138 


142 


146 


151 


155 


160 


165 


169 


23.... 


106 


109 


113 


116 


119 


123 


127 


130 


135 


138 


143 


147 


152 


156 


161 


166 


170 


24.... 


107 


110 


114 


117 


120 


124 


128 


131 


136 


139 


144 


148 


153 


157 


162 


167 


171 


25.... 


108 


111 


114 


118 


121 


125 


128 


132 


136 


140 


144 


149 


154 


158 


163 


168 


172 


26.... 


108 


111 


115 


118 


122 


126 


129 


133 


137 


141 


145 


150 


154 


159 


164 


169 


173 


27.... 


109 


112 


116 


119 


122 


127 


130 


134 


138 


142 


146 


150 


155 


160 


165 


170 


174 


28.... 


109 


112 


116 


120 


123 


127 


130 


134 


138 


142 


147 


151 


156 


161 


166 


170 


175 


29.... 


110 


113 


117 


120 


124 


127 


131 


135 


139 


143 


148 


152 


157 


162 


167 


171 


176 


30.... 


110 


114 


117 


121 


124 


128 


132 


136 


140 


144 


148 


152 


157 


162 


167 


172 


177 


31.... 


111 


114 


118 


121 


125 


129 


132 


136 


140 


145 


149 


153 


158 


163 


168 


173 


178 


32 ... . 


111 


115 


118 


122 


125 


129 


133 


137 


141 


145 


150 


154 


159 


164 


169 


173 


179 


33.... 


112 


115 


119 


122 


126 


130 


133 


138 


142 


146 


150 


155 


159 


164 


170 


174 


179 


34.... 


112 


116 


119 


123 


126 


130 


134 


138 


142 


147 


151 


155 


160 


165 


170 


175 


180 


35.... 


112 


116 


120 


123 


127 


131 


134 


139 


143 


147 


152 


156 


161 


166 


171 


175 


181 


36.... 


113 


117 


120 


124 


127 


131 


135 


139 


143 


148 


152 


156 


161 


166 


172 


176 


181 


37.... 


113 


117 


120 


124 


128 


131 


135 


140 


144 


148 


153 


157 


162 


167 


172 


177 


182 


38.... 


113 


117 


121 


124 


128 


132 


136 


140 


144 


149 


153 


158 


162 


167 


173 


177 


183 


39.... 


114 


118 


121 


125 


129 


132 


136 


141 


145 


149 


154 


158 


163 


168 


173 


178 


183 


40.... 


114 


118 


122 


125 


129 


133 


136 


141 


145 


149 


154 


158 


163 


168 


173 


178 


184 


41.... 


114 


118 


122 


125 


129 


133 


137 


141 


146 


150 


154 


159 


164 


168 


174 


179 


184 


42.... 


115 


118 


122 


126 


130 


133 


137 


142 


146 


150 


155 


159 


164 


169 


174 


179 


185 


43 ... . 


115 


119 


123 


126 


130 


134 


138 


142 


146 


151 


155 


161 


165 


170 


175 


180 


185 


44.... 


115 


119 


123 


126 


130 


134 


138 


143 


147 


151 


155 


161 


165 


170 


175 


180 


186 


45.... 


116 


119 


123 


126 


131 


134 


138 


143 


147 


151 


156 


161 


165 


170 


176 


181 


186 


46.... 


116 


119 


123 


127 


131 


135 


139 


143 


147 


152 


156 


161 


166 


170 


176 


181 


186 


47 ... . 


116 


120 


124 


127 


131 


135 


139 


144 


148 


152 


157 


161 


166 


171 


176 


181 


187 


48.... 


116 


120 


124 


127 


131 


135 


139 


144 


148 


152 


157 


161 


166 


171 


177 


182 


187 


49.... 


117 


120 


124 


127 


131 


135 


139 


144 


148 


153 


157 


162 


167 


171 


177 


182 


187 


50.... 


117 


120 


124 


127 


132 


136 


140 


144 


148 


153 


157 


162 


167 


172 


177 


182 


188 


51 ... . 


117 


120 


124 


128:132 


136 


140 


145 


149 


153 


158 


162 


167 


172 


178 


182 


188 


52.... 


117 


121 


125 


128|132 


136 


140 


145 


149 


153 


158 


162 


167 


172 


178 


183 


188 


53.... 


117 


121 


125 


128 132 


136 


140 


145 


149 


154 


158 


163 


168 


172 


178 


183 


188 


54.... 


118 


121 


125 


128 132 


136 


140 


145 


149 


154 


158 


163 


168 


173 


178 


183 


188 


55.... 


118 


121 


125 


128 


132 


136 


140 


145 


149 


154 


158 


163 


168 


173 


178 


183 


188 



This table is quoted from Ortner's " Treatment of Internal Diseases. 



OBESITY 



67 



WEIGHT TABLE (Female) 1 

(Showing average weight for each height and age. Based on "Nylic Graphic 

Table. ") 



Age. 


57 


58 


59 


60 


61 


62 


63 


64 


65 


66 


67 


68 


69 


70 


71 


72 


73 


Ins. 


Ins. 


Ins. 


Ins. 


Ins. 


Ins. 


Ins. 


Ins. 


Ins. 


Ins. 


Ins. 


Ins. 


Ins. 


Ins. 


Ins. 


Ins. 


Ins. 


20.... 


100 


103 


106 


109 


113 


116 


120 


123 


127 


130 


134 


138 


142 


147 


152 


156 


161 


21.... 


101 


104 


107 


110 


114 


117 


120 


124 


127 


131 


135 


139 


143 


148 


152 


157 


162 


22.... 


101 


105 


107 


110 


114 


118 


121 


124 


128 


132 


136 


140 


144 


149 


153 


158 


162 


23.... 


102 


105 


108 


111 


115 


118 


122 


125 


128 


132 


137 


140 


145 


149 


154 


158 


163 


24.... 


102 


106 


108 


111 


115 


119 


122 


126 


129 


133 


137 


141 


145 


150 


155 


159 


164 


25.... 


103 


106 


109 


112 


116 


119 


123 


126 


130 


134 


138 


142 


146 


151 


155 


160 


165 


26 ... . 


103 


107 


110 


113 


117 


120 


124 


127 


131 


134 


139 


143 


147 


151 


156 


161 


166 


27.... 


104 


107 


110 


113 


117 


121 


124 


128 


131 


135 


139 


144 


148 


152 


157 


162 


166 


28.... 


104 


108 


111 


114 


118 


121 


125 


128 


132 


136 


140 


144 


149 


153 


158 


162 


167 


29.... 


105 


108 


111 


114 


118 


122 


126 


129 


133 


136 


141 


145 


149 


154 


158 


163 


168 


30.... 


105 


109 


112 


115 


119 


123 


126 


129 


133 


137 


141 


146 


150 


154 


159 


164 


169 


31.... 


106 


109 


112 


116 


119 


123 


127 


130 


134 


138 


142 


146 


151 


155 


160 


165 


170 


32.... 


106 


110 


113 


116 


120 


124 


127 


131 


135 


138 


143 


147 


151 


156 


161 


166 


170 


33.... 


107 


110 


113 


117 


120 


124 


128 


131 


135 


139 


143 


148 


152 


156 


162 


166 


171 


34. . . . 


107 


110 


114 


117 


121 


125 


128 


132 


136 


140 


144 


149 


153 


157 


162 


167 


172 


35.... 


108 


111 


115 


118 


122 


125 


129 


133 


137 


140 


145 


150 


154 


158 


163 


168 


173 


36.... 


108 


112 


115 


119 


122 


126 


130 


133 


137 


141 


146 


150 


154 


159 


164 


169 


174 


37 ... . 


109 


112 


116 


119 


123 


126 


130 


134 


138 


142 


146 


151 


155 


160 


165 


170 


175 


38.... 


109 


113 


116 


120 


123 


127 


131 


135 


139 


142 


147 


152 


156 


161 


166 


170 


175 


39.... 


110 


113 


117 


120 


124 


128 


131 


135 


139 


143 


148 


153 


157 


161 


166 


171 


176 


40.... 


110 


114 


117 


121 


124 


128 


132 


135 


140 


144 


148 


153 


157 


162 


167 


172 


177 


41.... 


111 


114 


118 


121 


125 


129 


132 


136 


140 


145 


149 


154 


158 


163 


168 


173 


178 


42.... 


111 


115 


118 


122 


125 


129 


133 


137 


141 


145 


150 


155 


159 


163 


169 


173 


179 


43.... 


112 


115 


119 


122 


126 


130 


134 


138 


142 


146 


150 


156 


159 


164 


169 


174 


179 


44.... 


112 


116 


119 


123 


127 


130 


134 


138 


142 


147 


151 


156 


160 


165 


170 


175 


180 


45.... 


113 


116 


120 


123 


127 


131 


135 


139 


143 


147 


152 


157 


161 


166 


171 


175 


181 


46.... 


113 


117 


120 


124 


128 


131 


136 


139 


143 


148 


152 


157 


162 


166 


171 


1176 


182 


47.... 


114 


117 


121 


124 


128 


132 


136 


140 


144 


149 


153 


158 


162 


167 


172 


177 


182 


48.... 


114 


118 


121 


125 


129 


133 


137 


141 


144 


149 


154 


159 


163 


168 


173 


178 


183 


49.... 


115 


118 


122 


125 


129 


133 


138 


141 


145 


150 


154 


159 


164 


168 


174 


179 


184 


50.... 


115 


119 


122 


126 


130 


134 


138 


142 


146 


150 


155 


160 


164 


169 


174 


179 


185 


51.... 


116 


119 


123 


126 


130 


134 


139 


143 


147 


151 


156 


161 


165 


170 


175 


180 


186 


52.... 


116 


120 


123 


127 


131 


135 


139 


143 


147 


152 


156 


161 


166 


170 


176 


181 


186 


53.... 


117 


120 


124 


127 


131 


135 


140 


144 


148 


153 


157 


162 


166 


171 


177 


182 


187 


54.... 


117 


120 


124 


128 


132 


136 


140 


144 


148 


153 


158 


162 


167 


172 


177 


182 


188 


55.... 


118 


121 


125 


128 


132 


136 


140 


145 


149 


154 


158 


163 


168 


173 


178 


183 


188 



1 This table is quoted from Ortner's "Treatment of Internal Diseases.' 



The above studies furnish us with standards of weight and 
food. When, therefore, an obese patient comes to us we should 
from these tables ascertain what should be his weight and food in- 
gestion. We then proceed to arrange a dietary. To do this we 
need the fuel value of the different foods. This is found in the 
following table, from page 28 of Farmers' Bulletin No. 142 of the 
U. S. Department of Agriculture: 



68 



SYMPTOMATIC THERAPEUTICS 



NUTRIENTS AND ENERGY OF DIGESTIBLE PORTION OF SOME 
COMMON FOODS, WITH NUTRITIVE RATIOS 1 



Kind of Food Materials. 



Animal Food. 
Beef, fresh: 

Chuck, ribs 

Loin, medium 

Ribs 

Round, medium 

Shoulder and clod 
Beef, dried and smoked 



Veal: 

Cutlets, round. 
Leg 



Mutton: 
Leg.. 
Loin. 



Pork, fresh: 
Loin, chops. 
Ham 



Pork, salted and smoked: 

Bacon 

Ham 

Salt, fat 



Poultry: 
Fowl. . . 
Turkey. 



Fish, fresh: 
Cod, dressed 
Mackerel 



Shellfish: 

Oysters, solids 

Fish, preserved and canned: 

Cod, salt 

Salmon, canned 

Eggs, uncooked 



Per 

cent 



4.7 



3.4 
14.2 



18.4 
16.0 



7.7 
13.6 



25.9 
22.7 



29.9 
44.7 



24.9 



11.2 



Per 

cent 

52.6 

52.5 

43 

60.7 

56.8 

53.7 



68.3 
60.1 



51.2 
42.0 



41 

48.0 



17 
34 
7.9 



47.1 
42.4 



58.5 
40.4 



88.3 



40.2 
63.5 
65.5 



Ire 



Per 

cent 



1 
1 

1.8 
1.4 

1 
4 



Digestible Nutrients, 



Per 

cent. 



15.0 
15.6 
13.5 
18.4 
2 15.9 
5 25.6 



19.5 
15.0 



1.414.6 
2.013.1 



1.8 
1.9 



4.4 
3.1 
5.4 



1.2 
1.6 



5.1 
1.9 
1.1 



Per 

cent 

14.3 
16.6 
20.0 
12.2 
9.3 
6.6 



7.1 

7.5 



14.0 
26.9 



13.023.0 
13.124.6 



8.859.1 
13.831.7 

1.881.9 



13.3 
15.6 



10.8 
9.9 



5.8 



15.5 
21.1 
12.7 



11.7 
17.5 



.2 
4.0 



1.2 



.4 
11.5 



!2 B 



Per 

cent 



3.3 



Per 

cent. 

0.6 

.7 
.5 
.8 
.7 
5.5 



3.1 
3.2 
2.9 



13.9 
2.0 

.7 



ft 
m ft 



Calo- 
ries. 

910 
1,025 
1,135 
890 
715 
790 



695 
625 



890 
1,415 



1,245 
1,320 



2,720 
1,635 
3,555 



765 
1,060 



220 
370 



225 



325 
915 
635 



Calo- 
ries. 

2.1 
2.4 
3.3 
1.5 
1.3 
.6 



.8 
1.1 



2.2 
4.6 



4.0 
4.2 



15.1 
5.2 



2.0 
2.5 



1.0 



.1 
1.2 
1.7 



1 " Nutritive ratio " is the ratio of the digestible proteins to the digestible fats 
and carbohydrates. The normal ratio is 1 to 3 J or 4 (Williams). For a detailed 
discussion of this matter, see Williams's " Food and Diet," pp. 188, et seq. 



OBESITY 



69 



NUTRIENTS AND ENERGY OF DIGESTIBLE FOODS.— Continued. 



Kind of Food Materials. 



Animal Food. — Continued. 

Dairy products: 

Whole milk 

Skim milk 

Cream 

Butter 



Vegetable Food. 

Cereals, etc.: 

Corn meal 

Oat breakfast food 

Rye flour 

Rice 

Wheat flour, patent process . 
Wheat breakfast food 



Bread, etc.: 

Bread, white wheat. 
Crackers, cream .... 



Vegetables: 

Beans, white, dried. . 

Beets, fresh 

Cabbage 

Potatoes 

Squash 

Sweet potatoes, fresh. 
Tomatoes 



Fruits: 

Apples 

Bananas 

Grapes 

Oranges 

Strawberries . 



Per 
cent. 



20.0 
15.0 
20.0 
50.0 
20.0 



25.0 
35.0 
25.0 
27.0 
5.0 



Per 
cent. 

87.0 
90.5 
74.0 
11.0 



12.5 

7.8 
12.9 
12.3 
12.0 

9.6 



35.3 

6.8 



12.6 
70.0 
77.7 
62.6 
44.2 
55.2 
94.3 



63.3 
48.9 
58.0 
63.4 

85.9 



"3 a 



Per 

cent. 

.5 

.3 

1.1 

4.9 



3.3 
5.1 

2.9 
2.9 
3.4 

3.8 



2.9 
4.5 



1.2 
1.6 
1.7 
1.0 
1.0 



Digestible Nutrients. 



Per 

cent, 



3.2 
3.3 

2.4 



Per 

cent. 

3.8 
.3 
17.6 
1.080.8 



7.8 
14.2 
5.8 
6.8 
9.7 
10.3 



7.8 
8.2 



17.5 
1.1 
1.2 
1.5 

.6 
1.2 

.7 



1.2 

10.9 



1.6 
.1 

.2 
.1 
.2 
.5 
.4 



.3 
.4 
1.1 
.1 
.5 



«T5 

o >> 



Per 

cent, 



5.0 
5.1 
4.5 



73.9 
64.9 
77.1 
77.4 
73.6 
73.7 



52.0 
68.3 



57.8 
7.3 
4.6 

14.0 
4.3 

20.8 
3.7 



9.7 
12.9 
13.0 

7.7 
6.3 



Per 

cent 



.5 

.5 

.4 

2.3 



.8 
1.4 
.5 
.3 
.4 
1.0 



1.3 



2.6 

.7 
.7 



> O 

— , a 



Calo- 
ries. 

310 

165 

865 

3,410 



1,640 
1,800 
1,620 



Calo- 



4.3 

1.8 

18.4 



10.0 

5.6 

13.6 



1,625 11.5 



1,635 
1,680 



7.8 
7.5 



1,200 7.0 
1,925 11.3 



1,520 
160 
115 
295 
100 
440 
95 



190 
260 
295 
150 
150 



3.5 

6.8 
4.2 
9.5 
7.8 
18.3 
6.6 



34.7 
19.7 
17.2 
15.8 
9.3 



Sometimes, instead of putting the patient on the dietary normal 
for his age and size, we reduce the dietary to the lowest limits and 
give him a " hunger cure," according to the suggestions of Bant- 
ing, Oertel, or Ebstein. In these starvation dietaries care must 



70 SYMPTOMATIC THERAPEUTICS 

be taken to keep the protein about normal and to put the chief 
reduction on the fats and carbohydrates. By reducing these grad- 
ually we can compel the body to use up its own superfluous fats 
and yet not cause the patient great discomfort. Of course the pa- 
tient's heart and urine must be watched to prevent weakening him 
with too little food. A dietary for this purpose suggested by De 
Bove and recommended by Oertel is the following: 

Breakfast — Cup of tea with milk. 

Dinner — 1 to 2 slices lean meat, small amount of green vege- 
tables or salad, 3 to 5 oz. (100 to 150 gm.) of bread, cheese, fruit 
(freely), cup of black coffee (without sugar). 

Supper — 1 pint hot sugared milk, 1 to 1J oz. (30 to 50 gm.) 
bread (without butter), fruit (freely). 

Ten drops of the tincture of aloes are given before each 
meal. 

After the required reduction in weight has been obtained, a 
normal dietary is given and the patient asked to adhere to it for 
months. 

The next means of reducing the patient's weight is that of 
graduating his exercise. If he can go to the mountains and live a 
vigorous out-of-door life, the desired result is obtained with very 
little detailed prescription, because the altitude of itself assists in 
the reduction and the food in the mountains is usually coarse and 
wholesome. 

Men who are otherwise healthy may be subjected to fatigue 
cures, such as that at White Plains, N. Y., where the patient is 
made to run across the country five or six miles even at the start, 
to ride horseback, to box, etc., until he is utterly exhausted. This 
is kept up until the muscles grow strong and the fat disappears. 
Of course such a cure demands constant supervision and regu- 
lation. 

Patients who are not otherwise strong are subjected to hot-air 
baths and massage. The hot-air cabinet is given daily for about 
one hour with the temperature at 200° to 250° F. At its close the 
patient is rubbed off thoroughly with water at 60° to 70° F. 

If necessary, patients may be required to take walks after their 
meals instead of taking naps, and to restrict their sleep to seven or 
eight hours nightly. 

For medication one simply uses mineral waters or saline laxa- 



CONVULSIONS 



71 



tives to keep the bowels loose. The value of the treatment at the 
various " springs " lies in the regulation of the life rather than 
in the virtue of the waters. 

For the pain of adiposa dolorosa we find that inunction with 
fifty-per-cent oil solution of guaiacol and the continued use of the 




Fig. 9. — Hot-air Cabinet, Arranged for Gas Heat. 



thermophore are very effective. The former may be used in one- 
half -dram doses t. i. d., and the latter three or more times for about 
fifteen minutes. 

XIII. CONVULSIONS 

The term convulsions is used very freely and seems to include 
both spastic and flaccid types of seizures, and of the former both 
tonic and clonic spasms. We have, therefore, the term applied to 
attacks of eclampsia, of uremia, of hysteria, of ptomain and 
strychnin poisoning, of epilepsy, of meningitis, of simple hyper- 
pyrexia in childhood. 

The symptomatic relief must depend upon the type of the seiz- 
ure, for such relief must release the spasm in the spastic type and 
stimulate the nerve centers in the flaccid type. Then, again, we 
must distinguish organic and functional attacks; that is, if the 



72 SYMPTOMATIC THERAPEUTICS 

attack be due to emotional disturbance we should proceed very 
differently from the way in which we would approach a case of 
strychnin or other " convulsant " poisoning. 

If now we find our patient rigid and made worse by touch- 
ing or moving, we judge that we have the tonic spastic type of 
convulsion before us. Then, if we have reason to believe that we 
can exclude hysteria or emotional shock, we administer the bromids 
and chloral. Thus, we might give 15 grains (1 gram) each of po- 
tassium bromid and chloral hydrate in an ounce of hot water. If 
the patient cannot swallow, we should give it by the rectum. The 
administration of chloroform by inhalation may be begun at the 
same time. 

On the other hand, if we think that the attack is hysterical, or 
if we think that it is due to poisons or fermenting food in the 
stomach, we should inject at once subcutaneously one tenth or one 
fifth of a grain of apomorphin. This drug, besides emptying the 
stomach, has considerable sedative effect on the higher centers. 
The effect should appear within fifteen minutes. 

In tetanus (lockjaw), the opisthotonos will be relieved by the 
lumbar injection of magnesium sulphate (see Tetanus). 

Morphin (one fourth to one half grain) may also be of use in 
the lighter types of convulsions. 

Now should the seizure be of the flaccid type, we choose strong 
stimulants. Thus, we may slap the patient with towels wet in ice- 
cold water, or may apply first hot, then cold, fomentations. We 
may at the same time hold a bottle of ammonia under the patient's 
nose, or we may give a teaspoonful of the aromatic spirits of am- 
monia. Both of these measures (the cold cloths and the ammonia) 
afford quickly acting but evanescent stimulation to the medullary 
centers through the medium of the skin (or gastric) reflexes. 
Therefore, when such reflexes are depressed, inhibited, or ex- 
tinguished, such measures fail. When they do fail we must have 
recourse to the subcutaneous or intravenous injection of such drugs 
as strychnin, nitroglycerin, ergotoxin (or aseptic ergot), adrenalin, 
pituitary substance, etc. Even in the flaccid type of convulsion 
we often find occasion to resort to the subcutaneous injection of 
apomorphin. 

During either sort of attack the patient should be freed from 
all tight clothing, especially that of the neck and chest, and laid 



CONVULSIONS 73 

flat in the open air or in a well-ventilated room. Idle bystanders 
should be kept out and every obstacle to the free access of pure 
air removed. 

When we learn the cause of the attack our therapy may be 
much more rational and effective. Thus, in eclampsia we must 
reduce the blood pressure. This is accomplished by the use of the 
nitrites (sodium nitrite, 2 grains, or, better, nitroglycerin, T ^ 
grain), or veratrum viride (two to five drops of the fluid extract). 
Venesection also accomplishes a similar result. The causal treat- 
ment is, of course, the emptying of the uterus, and this should be 
attended to at once. 

In uremia a preliminary dose of morphin, followed by thorough 
diaphoresis and catharsis, is necessary. Pilocarpin (J grain) sub- 
cutaneously may be of value when the heart is not weak. Gener- 
ally, however, hydrotherapy is needed (see Uremia). 

Hysterical convulsions are usually best relieved by apomorphin 
subcutaneously. After the relief of the seizure, interval treatment 
should be undertaken according to the principles discussed else- 
where. 

Poisoning by strychnin requires the apomorphin, followed by 
thorough gastric lavage. Here the sedative effects of the bromids 
and chloral are demanded (30 to 40 grains of each). The nitrites 
also may be of use. 

Ptomain poisoning usually demands active catharsis (castor 
oil and salts) and diaphoresis (pilocarpin), followed by the tonic 
action of caffein or strychnin, as the symptoms may demand. 

Epileptic seizures require only good care, removal of tight 
clothing, access to pure air, rest, and the prevention of the pa- 
tient's biting himself. This last is cared for by slipping a cork 
between the teeth. 

The seizures due to meningeal irritation are helped by apply- 
ing heat to the feet and ice to the head, to influence the flow of 
blood away from the inflamed area. Atropin may frequently be 
needed to overcome some of the rigidity. This should be given 
with the needle in y^-g-- to -^--grain doses. 

In the simple convulsions of infancy the best procedure is to 
empty the bowels thoroughly with soapsuds enemata and apply 
hot packs to set up diaphoresis. 

Thus, in each case we seek to remove the irritant or counteract 



74 SYMPTOMATIC THERAPEUTICS 

it. We apply our counteraction to the medulla (chloral), spinal 
cord (bromids), or end plates (atropin), according to our belief as 
to the location of the irritation. Hence, the closer our diagnosis the 
more specific and satisfactory our treatment. "We should never be 
satisfied with the diagnosis " convulsions/' 



CHAPTER II 

THE TREATMENT OF LOCALIZED INFLAMMATIONS 

I. ACUTE INFLAMMATIONS 

The three elements which from our standpoint must receive 
most thought in any localized inflammation are: (1) the individual 
cells, (2) the local circulation, and (3) the reflexes. The individ- 
ual cells react to inflammation first by increased cellular activity, 
including proliferation, and secondly, if the inflammation be too 
severe or prolonged, by becoming depressed and finally by dying. 
Hence, the degree of the inflammation is an important factor in de- 
termining the therapeutic indication. 

The second element, the circulation, is affected first by the dila- 
tion of the capillaries and the exudation of the hemic elements. 
When continued, this dilation causes the walls of the capillaries 
to become fixed in dilation, and the flooding of the surrounding 
tissues leads to the production of fibrous tissue with a coincident 
death of the parenchymatous tissue. 

The third element, the reflexes, differs, of course, with the in- 
dividual. The swelling of the tissues puts the contained nerve 
fibers and end plates on a stretch, and produces pain, or at least 
discomfort. The psychic element then enters and stimulates or 
depresses, as the individual feels, the supply of nutrition to the 
affected part. 

We may present the above in another form and say that there 
are three degrees of localized inflammations: (1) A stage of active 
congestion and cellular stimulation — that is, a stage of increased 
function; (2) a stage of passive congestion and cellular depres- 
sion — that is, decreased function; and (3) the stage of death. 

Now from the time of Greek medicine the cardinal symptoms of 
acute inflammation have been redness (rubor), heat (calor), swell- 
ing (tumor), pain (dolor), and finally disturbed function. The 

75 



76 TREATMENT OF LOCALIZED INFLAMMATIONS 

redness is due to the suffusion of the parts with blood, the heat to 
the increased activity of the tissues, the swelling to the congestion, 
the pain to the distention of the tissues, and the disturbed function 
partly to the cellular changes and partly to the reflexes. Some of 
the symptoms are useful, some detrimental, according to the cause 
of the inflammation and their effect on the local condition. Thus, 
the suffusion of the tissues with fresh blood brings to the inflamed 
cells the assistance of the opsonins and other protective agencies of 
the blood serum; but the suffusion of the tissues with stagnant 
blood, or serum with little or no active bactericidal power, would 
only weaken, not strengthen, them. Then, again, we may consider 
that intrinsically those symptoms are valuable which are the re- 
sult of the body's reaction to the cause of the inflammation, and 
those liable to be detrimental which are the direct result of the 
causa morhi. Thus, the redness and heat, in so far as they are due 
to the body's reaction, are instrumental in discouraging the in- 
flammatory processes, but where they are the result of active com- 
bustion of tissue by microbic processes they indicate an injurious 
process and should be checked. Hence, here as with the other 
symptoms, we must convince ourselves that they are injurious be- 
fore we institute procedures to do away with them. 

The treatment must consider all three elements (cells, circula- 
tion, and reflexes), but practically must be directed chiefly toward 
controlling, or at least influencing, the circulation. For it is by 
increasing or decreasing the flow of blood that we may hope to 
supply fresh and active blood serum, or to free the tissues from the 
excessive and stagnant fluids and stimulate the growth and pro- 
liferation of healthy cells. Then, too, by checking excessive dila- 
tion of the blood capillaries and by securing more complete drain- 
age, we lessen the tension and decrease the pain. 

We can influence the circulation by raising or lowering the part 
with reference to the rest of the body ; thus, we sometimes suspend 
a leg vertically or at right angles to the body lying in the bed, or 
lower the head when we wish to increase the blood flow thereto. 
We can apply a tight bandage and compress the blood vessels, 
thus overcoming some of the dilation. We can apply heat to in- 
crease the flow of blood or cold to check it. We can tap a vein and 
remove considerable blood and secure a reactive contraction of the 
blood vessels, or we can apply a vacuum cup and increase the 



ACUTE INFLAMMATIONS 77 

amount of blood in the area covered by the cup. We may secure 
a hyperemia by applying a counterirritant to the overlying sur- 
face, or by using the counterirritation in another part of the cir- 
culatory system decrease the flow of blood to the affected area. 
Finally, we may use drugs to increase or decrease the lumen of the 
blood vessels, some by their local action, such as adrenalin or 
eucain ; some by their systemic effects, such as atropin or digitalin. 

As may be seen by the above discussion, one of the dangers in- 
cident to inflammation is the breaking down of the capillary walls 
because of the prolonged distention and flooding. This is to be 
prevented by the methods outlined above (position, compression, 
cold, etc.), and should be looked after even if our attention is not 
directly called to it. 

The use of Bier's hyperemia, now so much the vogue, depends 
for its usefulness upon increasing the blood supply to the affected 
area, and thus furnishing the tissues with better and more active 
blood serum. When it is done by vacuum it is dependent upon the 
same principles as the cupping mentioned above ; when it is accom- 
plished by ligatures, it secures its results by checking the return 
flow of blood and thus increasing the amount of serum in the tissues. 

Similarly, hot and cold baths and other forms of hydrotherapy 
depend for their usefulness upon their influence on the circula- 
tion. Thus, holding an inflamed hand in hot water increases the 
blood supply, in cold water decreases it — which should be done 
depends upon the momentary and local condition. Thus, hot tub 
baths bring the blood to the surface, and decrease the amount in 
the viscera in visceral inflammations. In this connection, it may 
be well to recall the fact that the first flushing of the skin in a hot 
bath is followed by an attempt of the vasomotor system to equalize 
the circulation and contract the skin capillaries, and that a cold 
bath produces a reaction wherein an increased blood supply is sent 
to the skin in an attempt to overcome the chill. But if either sort 
of bath is maintained long the vasomotor control becomes para- 
lyzed, and we have only the direct physical effects of the heat or 
cold. Therefore, with short baths, the chief effect is a stimulation 
of the vasomotor centers and the better and quicker interchange of 
blood throughout the whole body. 

Poultices are a means of using heat to produce hyperemia, and 
are useful only in so far as they do this better than the other means 



78 TREATMENT OF LOCALIZED INFLAMMATIONS 

just mentioned. In general, we should select that form of poultice, 
when we find it necessary to use a poultice at all, that is most 
cleanly and pleasant. Nearly everything that will hold moist heat 
has been used at one time or another for poultice material. At 
present in good usage the materials are linseed, bread, starch, clay, 
and mustard (sinapism). 

Linseed poultices are made by pouring one cup of linseed (flax- 
seed) meal into two and one half cupfuls of boiling water and stir- 
ring until a thick mush is formed. This should be spread while still 
warm (as warm as can be borne comfortably) on a piece of flannel 
and covered with the same material and then applied to the area 
affected. A new poultice should be applied as soon as the old one 
is cold, and the skin should not be allowed to cool during the 
change. This poultice is irritant to delicate skin. A pinch of bak- 
ing soda added to the boiling mixture may help to overcome this 
defect. 

Bread poultices are made by cutting the bread into thick slices, 
covering with boiling water, and letting the mixture stand say for 
five minutes. The water should then be poured off. Fresh boiling 
water should be added and the mixture allowed to simmer. The 
bread should then be drained and beaten smooth with a fork, then 
spread on a cloth and applied like the linseed poultice. 

Starch paste is made by stirring the starch in cold water until 
it forms a smooth mixture. Boiling water should then be added 
until the right consistency is obtained. 

The clay poultices are made two thirds of clay, one third of 
glycerin, with four and one half per cent of boric acid and a few 
drops of essential oils (especially wintergreen). This mixture is 
heating by setting the vessel containing it in water until the de- 
sired temperature is obtained. It is usually applied with a case 
knife direct to the skin, although it may be used like the other poul- 
tices named. It is less irritating than the others and more anti- 
septic. But even then it is less usable than a thermophore or other 
similar means of applying heat. 

The danger of infection should be ever in mind in applying a 
poultice, for the maceration incident to the poultice favors infec- 
tion, even if under ordinary circumstances one might consider the 
area germ proof. 

In the mustard poultice we have another element (besides the 



ACUTE INFLAMMATIONS 79 

moist heat) to deal with, and that is the irritant (vesicant) influ- 
ence of the oil which is developed on the addition of water. Black 
mustard is used (one pound of ground mustard to from five to ten 
pounds of flour) and is made into a paste with lukewarm water 
and then spread on a cloth (thinner than linseed) and applied for 
fifteen to thirty minutes, or until the skin tingles and looks red. 
The influence of mustard may also be obtained by using mustard 
papers, by sprinkling mustard (powdered) on a linseed poultice, 
or by using flannels wrung out in one tenth to one fifth solution of 
mustard oil in fifty per cent alcohol. Mustard foot baths are made 
by adding one to two ounces of mustard to the gallon of water. A 
mustard bath for a child is made by adding a large tablespoonful 
of mustard to the child 's tub of water. The child should be im- 
mersed only until the arms of the nurse begin to tingle. In using 
mustard in a poultice one should always guard against vesication, 
and when the mustard is removed one should always wash off the 
skin with warm water, and if there be blisters cover them with cot- 
ton. It need hardly be added that the use of mustard in modern 
practice is very much restricted and rare. Usually other and pleas- 
anter remedies may be found to do its work. 

So much for influencing the circulation directly. We must 
now consider the treatment of the two last cardinal symptoms in 
order to correlate this discussion with those in which the subject is 
viewed at another angle. 

The symptom to which our attention is most forcibly called is, 
of course, the pain. We assist in relieving this when we overcome 
the local redness and swelling, but usually — that is, in most pa- 
tients — we have to use some means of direct sedation on the pain 
itself. For, as we have indicated, the quality of pain depends upon 
the individual reaction, and with nervous persons pain is much 
more important than with phlegmatic. In choosing our means 
of relief we keep this in mind, and for the phlegmatic person may 
confine our analgesics to the locally acting ones, and for the nerv- 
ous persons choose the systemic drugs. Among the local measures 
we must classify rest, heat and cold, emollients and demulcents, 
local anesthetics, and counterirritants. Among the systemic anal- 
gesics we have morphin (opiates), coal-tar derivatives, and some- 
times the hypnotics. 

Physiological rest is good not only for the relief of pain, but 
7 



80 TREATMENT OF LOCALIZED INFLAMMATIONS 

also for the promotion of repair. Thus, it is causal as well as symp- 
tomatic in its influence. By rest we mean the cessation of use of 
the organ or part. Thus, for inflammation of the stomach we avoid 
the use of food by the mouth. For a broken bone, the application 
of splints and the rest of the muscles attached thereto affords the 
rest necessary to repair. For inflammation of the nerves, the ab- 
solute quiet of the parts to which these nerves are attached must 
be insisted upon. 




Fig. 10. — Applying Heat by Means of a 500-Candle-Power Electric Light. 



What we have already said about heat and cold should be re- 
membered when we speak of them for the relief of pain. Some- 
times we find that it is the heat that affords the greater relief, 
sometimes the cold. In general, we prefer to apply the cold in a 
beginning inflammation and the heat in an old one, because the 
cold may help check the inflammation, and in old inflammations 
the heat may stimulate repair. We apply the heat in the form of 
hot air, hot water, incandescent electric-light bulbs, hot-water bot- 
tles, poultices, and the cold by means of cold, moist cloths, ice bags, 
Leiter's coils, etc. 



ACUTE INFLAMMATIONS 81 

The emollients relieve pain chiefly by excluding air from 
abraded and inflamed surfaces; sometimes, indeed, they protect 
against the rubbing of clothing or the contact with rough objects. 
Most in use are lard, olive oil, wax, glycerin, starch, and cocoa 
butter. 

The demulcents are soft and jellylike, more or less nutritive 
materials, used for protecting inflamed surfaces in the intestinal 
tract. We use acacia, flaxseed, Iceland moss, starch, gelatin, etc. 
They therefore relieve pain to some extent, at least, when spread 
over the sensitive area. 

Counterirritation for the relief of pain is purely empiric. Thus, 
we may raise a blister on the back for the relief of spinal pain, or 
we may apply the actual cautery to the leg for the relief of sciatica, 
etc. Of course one element of relief is due to the distraction of 
attention. But aside from this there appears to be some influence 
due to the fact that the two sensations are simultaneous, and the 
relief seems almost physiologic in character. However, nowadays 
it is far better to secure this distraction and this ignoring of pain- 
ful impressions by direct psychotherapy. 

Of the systemic influences to relieve pain the opiates, and in 
particular morphin, deserve the first rank. Morphin acts by caus- 
ing the brain not to receive the impressions sent in from the in- 
flamed area. As we have noted elsewhere, this has no effect on the 
local condition and should be thought of purely as symptomatic 
treatment. 

So, too, the coal-tar derivatives. But it may be said of some 
of these that they are also antiseptic. Hence, in the microbic in- 
flammations the coal-tar analgesics may meet a causal as well as a 
symptomatic indication. 

Sometimes a systemic analgesic is not necessary, and a simple 
h'ypnotic, such as chloral, or a general sedative, such as a bromid, 
may be sufficient to induce sleep and rest. Accurately to gauge 
the degree of suffering so as to select exactly the drug most suited 
to the case will require much experience. In general, we prefer 
to err on the side of too weak rather than too strong a drug to 
quiet the patient. 

Finally, for the relief of disturbed function incident to acute 
inflammation there is nothing quite so efficacious as physiological 
rest. That is, the stimulation of cellular activity incident to mild 



82 TREATMENT OF LOCALIZED INFLAMMATIONS 

inflammations, such as an increase in the mucus discharged, is 
useful in so far as it promotes nutrition. But its continuance would 
bring harm both because it would interfere with the rest necessary 
for repair and because it changes the character or quality of the 
cellular products. Therefore, we give opium or tannin to check 
peristalsis in diarrhea, we stimulate the skin and bowels in ne- 
phritis to rest the kidneys, etc. In addition we may use crutches, 
both actual and metaphorical, to assist the organs or muscles in 
carrying out their work. Thus, we give predigested foods in cases 
of inflamed stomachs or intestines where it is impossible to use 
rectal feeding exclusively. We wash off mucous membranes with 
fluids analogous to the normal secretions. We take the load off 
bones and muscles by mechanical supports when they are inflamed 
and need rest. 

Of course, in the depression of cellular activity due to the 
higher grade of localized inflammation we must lend assistance and 
afford rest directly; for here it is the natural thing to do; only 
in the cases of hyperactivity did it seem abnormal. Vicarious 
activity of other cells or groups of cells must be secured to assist 
us in bringing about the conditions under which the injured tis- 
sues may regain their strength. 

Practically all inflammations produce some toxins, so that the 
term " intoxication " has become the generally accepted term for 
the systemic effects of more or less localized inflammations and even 
for systemic perversion of function for which we find no demon- 
strable cause. Thus gout and rheumatism are looked upon as in- 
toxications, although the causative toxin has not been satisfactorily 
demonstrated. On the other hand, the toxins of typhoid fever and 
diphtheria are thoroughly demonstrable. Hence, it becomes the 
duty of the physician not only to treat the local inflammation ac- 
cording to the principles above stated, but also to remove from the 
body the toxins resulting from the inflammation. 

In general, we make use of three channels of elimination: in- 
testine, kidney, skin, and the stimulation of one or all of these 
requires special thought in every case of systemic intoxication. We 
use calomel and salines to stimulate the intestine, theobromin com- 
pounds for the kidneys, and pilocarpin and hot baths for the skin. 



CHRONIC INFLAMMATIONS 83 

II. CHRONIC INFLAMMATIONS 

For an acute inflammation to become chronic, two factors are 
necessary: (1) persistence of the cause and (2) feeble reaction, 
or lack of reaction, from the body. Thus, gonorrhea tends to be- 
come chronic, because it can with extreme difficulty be eradicated 
from the local mucosa, and yet it does not excite a systemic reac- 
tion sufficient to influence its vitality. 

The pathological condition usually found in a chronic inflam- 
mation is characterized by an overgrowth of connective tissue with 
a decrease in parenchymatous tissue and an alteration in cell 
products, both in quantity and character. Thus, we find the blood 
vessels thickened, the septa thickened, secreting cells overstimu- 
lated, and the other parenchymatous cells apparently carrying on a 
losing battle against the encroachment of the fibrous tissue. 

The " cardinal " symptoms of an acute inflammation are no 
longer all present. There is apt to be some swelling and pain, but 
little or no redness and heat. The cellular function remains more 
or less disturbed, as might be inferred from our summary of the 
pathological findings. 

The treatment of chronic inflammation involves not only an at- 
tack upon the cause of the trouble, but also the stimulation of the 
body fluids to increased germicidal power, and the removal of as 
much as possible of the fibrous tissue. The first is accomplished by 
antiseptics, the second by vaccination, and the third by such agents 
as the X ray and fibrolysin — agents for destroying the less resist- 
ant cells, such as the pathological tissues always contain. The last 
function is also performed by caustics, such as carbolic acid and 
silver nitrate. 

1. Antiseptics 

Antiseptics are used for a direct attack upon microorganisms, 
and the ideal antiseptic would be one that would destroy the germs 
but not attack the body cells. Practically, none such has been 
found, and we therefore try to regulate the strength of the anti- 
septic solution so that the microorganisms are at least inhibited, 
while the body tissues hardly suffer at all. It is necessary to use 
antiseptics either locally or systemically (or both) in practically 
every inflammation, because, even if caused originally by a non- 



84 TREATMENT OF LOCALIZED INFLAMMATIONS 

living chemical agent, the derangement of function incident to the 
inflammation invites the growth of any bacteria present or near by, 
so that, sooner or later, every inflammation is a bacterial one. 

Of antiseptics there are many varieties and types, and we may 
classify them by cost, manner of action, chemical composition, 
or use. 

Thus, Wood gives the following table showing the relation of 
efficiency to cost: 

Mercury bichlorid = $0.01 

Silver nitrate = 0.22 

Phenol = 0.34 

Phenol sodique = 51.00 

Piatt 'schlorid = 66.00 

Listerine = 495.00 

Our comment is simply that the extensively advertised mixtures 
are expensive luxuries, and should be used only when the simpler 
antiseptics are not available. 

According to method of action, we find the following types: (1) 
mercury bichlorid forms a chemical union with protein to form an 
albuminate. It is therefore not selective in its action, but, accord- 
ing to the strength of the solution used, attacks everything with 
which it comes into contact. (2) Phenol, on the other hand, acts by 
destroying the nutrition of the cell; that is, it destroys the cells 
by altering their fluids. It acts more slowly and more selectively 
than the bichlorid, having little effect on dormant cells and spores. 
The coal-tar derivatives act, in general, like phenol. (3) Formalde- 
hyd acts by removing the fluids of cells and leaving them tanned or 
hardened and lifeless. It does not corrode metals, and is more 
selective, but also more irritant than mercury. (4) Potassium per- 
manganate and hydrogen peroxid oxidize the tissues with which 
they come into contact. Often, therefore, they have no effect at 
all on tissue cells, but simply destroy organisms that can live only 
in the absence of oxygen because they render the pabulum of the 
pathogenic bacteria unusable. 

Naturally, attempts are being made to combine the various 
types of antiseptics so as to secure all the advantages and none of 
the disadvantages of each. Needless to say, the attempts have been 
failures, except financially, and when we desire efficient service we 



CHRONIC INFLAMMATIONS 85 

still have recourse to the single antiseptic of the type desired in the 
special case. 

Thus, for sterilizing sputum, we use carbolic acid or formalin, 
because neither attacks the metal of the cup and neither loses its 
strength by combining with the albumen present. For sterilizing 
instruments, we use formalin or phenol. For sterilizing skin for 
an operation, we use corrosive sublimate in 1 : 1,000 solution. For 
cleansing out an abscess after opening it freely, we use bichlorid 
or peroxid. For internal antisepsis, we find that hexamethylena- 
min has some effect, but that the members of the coal-tar group 
must be our main reliance. Thus, we use creosote (guaiacol), salol, 
salicylates, etc., for toxemias and septicemias. For local washes, 
such as irrigation fluids for mucous membranes, we frequently use 
agreeably flavored antiseptic mixtures. The following formula is 
an example of a popular composition for this purpose : 

Boric acid 2.0 grams. 

Benzoic acid 0.1 

Thymol 0.1 

Eucalyptol 0.025 " 

Oil of peppermint 0.05 

Oil of wintergreen 0.025 ' ' 

Oil of thyme 0.01 

Alcohol 25.0 

Purified talc 2.0 

Water to make 100.0 

When we examine this formula, we realize that as far as intrinsic 
value is concerned the same results could be obtained with a much 
simpler mixture. Hence, we advocate in the following pages 
the making of extemporaneous prescriptions to fit the needs of 
each case. 

2. Vaccination 

The second method of attacking inflammations, that of exhib- 
iting either the sera of animals immunized to the particular bac- 
terium or the weakened toxin of the bacterium, is only in its in- 
fancy. It is, of course, the specific medication of which our 
philosophers for ages have dreamed, and even our little experience 



86 TREATMENT OF LOCALIZED INFLAMMATIONS 

has already demonstrated the fact that when the serum or vac- 
cine can be appropriately prepared and given the causa morbi 
must yield. 

In the case of the serums we neutralize the toxin or destroy the 
microbe by injecting into the blood stream of the patient its specific 
antibody. It does not require the patient to develop his own anti- 
body, and acts, therefore, more quickly and more independently 
of the patient than do the vaccines. Serums can be given, there- 
fore, to weaker patients and in more desperate cases than can vac- 
cines. The typical serum is that for diphtheria, which is given 
in 3,000 units and upward with only good results. This is made 
by immunizing horses to diphtheria, and then collecting and con- 
centrating their blood serum. Since this serum is a good type for 
study, we append the following notes from a recent pamphlet is- 
sued by a pharmaceutical house describing their preparation : 

Serum Therapy of Diphtheria. — The serum therapy of diphtheria is 
the use of antitoxic serum for curative or prophylactic purposes. The 
neutralization of the toxin by the antitoxin is due to a firm union be- 
tween the two substances. When the toxin and antitoxin are mixed 
outside the body at a given temperature and concentration, the rapidity 
and completeness with which the two unite is dependent upon the de- 
gree of affinity one has for the other. 

In the body the conditions are more complex. Two combinations are 
possible for the toxin generated by the growth of the diphtheria germs: 
one with the antitoxin which has been injected, and a second with the 
tissue cells. 

The union of the toxin with the cells finally becomes more than a 
chemical combination. Processes of a biological and biochemical nature 
occur and the toxin becomes an integral part of the protoplasm; when 
this occurs, no amount of antitoxin will effect a cure. 

It is important to recognize the fact that antitoxin cannot repair an 
injury already done by the toxin, the repair depending entirely on the 
recuperative power of the cells. 

The curative action of antitoxin consists not alone in neutralizing 
the circulating toxin, but in tearing away the toxin bound to the tissue 
cells and neutralizing it. A great excess of antitoxin is necessary to 
effect this, as is shown by the experiments of Donitz and of Madsen. 

These experiments show that while only a slight excess of antitoxin 
may be required to effect a cure if injected early in the infection, the 
quantity of antitoxin must be greatly increased as the case progresses. 



CHRONIC INFLAMMATIONS 87 

If the dose is not enough to neutralize the toxin, death invariably 
follows. 

Diphtheria antitoxin should be administered hypodermically. We 
suggest the following method of procedure: Cleanse the site of injec- 
tion, using warm water and soap, after which apply five-per-cent solu- 
tion of carbolic acid. The latter is antiseptic and produces a degree of 
local anesthesia which tends to overcome the pain of puncture by the 
needle. Any part of the body where the skin is loose may be selected. 
The best place is between the scapulae, since the patient cannot witness 
the injection, and is, therefore, less likely to be frightened. It is well 
to take this precaution in every instance where hypodermics are given 
to children, especially in diphtheria, because the heart is always affected 
by the toxins of the disease, and care must be exercised to prevent excite- 
ment. Inject the serum slowly and do not massage the parts. 

If there is one fact absolutely proved in serum therapy, it is the im- 
munizing value of diphtheria antitoxin to prevent contagion. While 
the immunity lasts only for a short time — three to six weeks — this length 
of time is amply sufficient to prevent the disease from spreading. As an 
immunizing dose 1,000 units are generally used. 

A therapeutic dose of antitoxin should never contain less than 3,000 
units. 

Children require larger doses than adults, as they have proportion- 
ately more surface for development of membrane; they are more sus- 
ceptible to the disease, and have less power of resistance. 

In treating a case of diphtheria, it is necessary to give enough anti- 
toxin to completely neutralize the toxin of diphtheria, since laboratory 
experiments prove conclusively that animals receiving an insufficient 
amount of antitoxin to neutralize the toxin of diphtheria die as surely 
as animals receiving no antitoxin. Hence, in a patient ill with diph- 
theria, since it is impossible to determine the virulence and the amount 
of toxin that has been secreted by the diphtheria germs, the only safe 
rule is to give sufficient antitoxin to produce the following characteristic 
reactions : 

When you have given enough antitoxin, the membrane shrivels, the 
odor becomes less fetid, the pulse becomes stronger, and the general con- 
dition of your patient is improved. Until all these conditions are ob- 
served, you have not given sufficient antitoxin, and repeated injections 
of double the initial dose should be made every six to eight hours until 
the above results are obtained. 

Finally, a serum does not confer a lasting immunity, its protec- 
tion enduring only until the antibodies introduced by the physician 
are exhausted. 



88 TREATMENT OF LOCALIZED INFLAMMATIONS 

Vaccines are made either by extracting the toxins of the bac- 
teria or by using the more or less macerated bodies of the 
bacteria. 

The purpose of vaccination is to excite the body to develop 
antibodies more quickly than would be done if the inflammatory 
focus were the only source of stimulation. Vaccination is also used 
(as for smallpox and typhoid) to render the body immune to a 
disease by producing these antibodies without having to undergo 
the exhausting sickness incident to having the real disease. A 
typical use of vaccination for curative purposes is in chronic otitis 
media. For in this disease so little of the bacterial toxin escapes 
into the blood stream that practically no antibodies are developed. 
Now, if a culture of the active bacteria is made and a few million 
of these bacteria are killed by heat and their bodies either ground 
up or macerated and then injected (in a vehicle of normal salt 
solution) under the patient's skin, a febrile reaction usually 
occurs, resulting in the production of antibodies which render 
the tissues of the diseased ear uninhabitable for the bacteria, 
and the inflammation ceases. So, also, for chronic gonorrhea 
and other inflammations accompanied by little or no systemic 
reaction. 

If the dosage of bacteria or toxin be too weak, there is danger 
of rendering the patient more, rather than less, sensitive to the dis- 
ease. On the other hand, too great doses make the patient very 
sick. Hence, the size and frequency of doses of vaccine is a matter 
requiring great study and care, for each patient must be treated 
individually and carefully watched all the time. To do this ef- 
fectively it is wise to keep the patient under observation for a few 
days before beginning the vaccine treatment in order to note the 
temperature range (the temperature is recorded every two hours) , 
to examine the blood and urine, and, in general, to learn as nearly 
as possible the exact condition of the patient's metabolism. Only 
with such a preliminary study can we interpret correctly the phe- 
nomena following the injection of the vaccine. The ideal dosage 
causes little or no fever and very little malaise, and the ordinary 
interval between doses in chronic affections should be from three 
to five days. (For further details, see the discussion of Vaccination 
for Chronic Urethritis.) 



INFLAMMATIONS OF THE SKIN 89 

3. Caustics, Etc. 

Finally, in treating inflammations, we must try to remove the 
sear tissue and other pathological formations. In simple and ac- 
cessible cases this is usually done with a caustic, such as phenol or 
silver nitrate. For the ' ' proud flesh ' ' and exuberant granulation 
tissue we usually apply pure liquid carbolic acid. For scars near 
vital organs, where we must avoid deep penetration, we use silver 
nitrate either in stick or as a ten-per-cent aqueous solution. In 
keloids and extensive scar tissues, where it is impracticable to use 
either the knife or a caustic, we find that the X-ray does good 
service in causing a dissolution of the tissues; but for the deep- 
seated adhesions and fibrous bands, such as, for instance, those 
resulting from cholecystitis, we have had no specific treatment. A 
few years ago thiosinamin, a product derived from the oil of mus- 
tard, was introduced to do this work. It was injected subcutane- 
ously with varying results, but the great pain accompanying the 
injection greatly limited its usefulness. Lately a salicylate of 
thiosinamin has been introduced under the name of fibrolysin, 
and this is now being tried out. Just enough success has ac- 
companied its trial to stimulate us to continue with it. It is 
therefore justifiable to try this drug in cases of painful or dis- 
figuring scar tissues. 

III. INFLAMMATIONS OF THE SKIN 

The exciting causes for skin inflammations may be grouped un- 
der (1) traumatic and (2) parasitic. Under the first we would 
include irritations, as from rough clothing or an ill-fitting shoe, 
as well as cuts, bruises, burns, and abrasions. Under the second we 
would include boils and similar bacterial inflammations, as well as 
the inflammations following the attacks of scabies and other para- 
sites. 

Skin inflammations are both acute and chronic. Some, however, 
are so mild in their symptoms that we must call them subacute. 
Then, on the other hand, we must note that we find many inflam- 
mations with all the earmarks of chronicity that have never been 
acute, thus differing from the general statement made above as to 
the onset of chronic inflammations. 



90 TREATMENT OF LOCALIZED INFLAMMATIONS 

1. Traumatic Inflammations of the Skin 

Burns. — The indications here are for the relief of the pain, the 
prevention of intestinal ulcers and shock, and the stimulation or 
assistance of the injured tissues to regeneration. 

The pain is relieved chiefly by excluding the air from the de- 
nuded tissues. If this is not sufficient, morphin is given hypo- 
dermically in one-fourth-grain doses. Coal-tar products should not 
be given because they increase the tendency to methemoglobin for- 
mation, thus being synergistic with the injury, which also tends 
toward the destruction of the blood corpuscles. 

The exclusion of the air is best accomplished by the application 
of an astringent yet soothing ointment, but in default of better 
material simple sterilized vaselin will render good service. Or, 
when even this is not at hand, bandages saturated in neutral oils 
(as cotton-seed oil) will be useful. Of the astringent ointments, the 
simple zinc oxid (twenty per cent) is as useful as any. If one de- 
sires a more active ointment in order to secure antiseptic and 
stimulating power, the compound resorcin ointment of the National 
Formulary may be chosen. Its formula follows : 

Resorcinol 6 parts. 

Zinc oxid 6 

Bismuth subnitrate 6 

Oil of cade 12 

Paraffin 10 

Lanolin 35 

Petrolatum 25 

In extensive burns it is better to use the permanent bath (see 
illustration) than ointments for the exclusion of air, because this 
also keeps the surface clean and stimulates repair. The patient 
may be kept in this for forty-eight hours. The water is kept evenly 
at body temperature (100° F.) and constantly flowing, so that 
there is no danger of stagnation and sepsis. 

In burns covering a large part of the body surface jejunal ul- 
cers have been found at the post-mortem examination. Whether 
they are due to the changes in the blood or to more local conditions 
is not settled. A regard for prophylaxis, however, demands that 



INFLAMMATIONS OF THE SKIN 91 

the bowels of the patient be kept open with saline cathartics (e. g., 
magnesium sulphate, \ oz. ; water, 4 oz. ; or calomel, \ grain every 
hour until the bowels act), and that the diet be simple and easily 
digested. Thus during the first few days eggnogs and rich soups 




Fig. 11. — The Permanent Bath. Note the heating chamber on the wall and the 
method of suspending the patient in the tub. (Courtesy of James B. Clow & 
Son, Chicago.) 

would be better than a general diet. The drinking of much water 
should be encouraged. 

Shock is essentially a temporary paralysis of the vasomotor 
system. It calls for vasomotor stimulants and vasoconstrictors. 
Heat is both prophylactic and remedial, and patients with severe 
burns need to be kept warm. The best vasoconstrictor in shock is 
ergot. But to be effective this must be given subcutaneously or in- 



92 TREATMENT OF LOCALIZED INFLAMMATIONS 

tramuscularly in comparatively large doses. If available, ergo- 
toxin should be preferred to the crude drug and should be given 
in doses of ten milligrams. The ernutin of Burroughs, Wellcome 
& Co., or the aseptic ergot of Parke, Davis & Co., are types of com- 
mercial preparations of ergot for subcutaneous use that should be 
always at hand for such emergencies as this. The dose of these 
preparations when given for shock should be, in general, twice the 
ordinary dose. 

The vasomotor stimulant for shock is strychnin, and this should 
be given subcutaneously. 

Adrenalin may also be used in place of ergot when the latter is 
not at hand. The dose should be ten to twenty-five drops of the 
1 : 1,000 solution injected into a vein or muscle. 

To introduce medicine into a vein one adopts, in general, the 
principles of phlebotomy (q. v.). Thus we prefer the median vein 
of the arm, but any exposed vein will do. We cleanse the surface 
with alcohol and ether, or soap and water and alcohol, place a com- 
press over the vein centrally from the selected site (the thumb of 
an assistant will do). As soon as the vein swells we introduce the 
needle into it, carefully avoiding the introduction of air, and 
pointing the needle parallel to the surface of the limb and in the 
direction of the blood current. The central pressure is now re- 
moved and the plunger of the syringe gently pressed home so that 
the fluid goes in slowly, drop by drop. As soon as the syringe is 
empty, the limb is raised above the level of the heart, the needle 
quickly pulled out, and slight pressure (best with a clean finger) 
is made over the puncture for a few minutes and then it is sealed 
with collodion. 

For intramuscular injections heavy muscles are desirable, 
therefore the glutei are preferred. When the injury does not pre- 
vent their use, the patient lies on his abdomen, the skin is cleansed 
with soap and alcohol, and the needle plunged for an inch or one 
and one half inches straight into the muscle of the buttocks. In 
obese patients the fat may be over an inch thick in this region, and 
we must always keep that figure in mind in inserting our needles. 
We must avoid plunging the needle into the tuber ischii or the 
ischiadic nerve. The best procedure is to take the needle from 
the syringe, sterilize it thoroughly, and insert it separately. We 
should watch for the escape of blood (indicating the puncture of a 



INFLAMMATIONS OF THE SKIN 93 

vein) or pain (indicating the puncture of a nerve trunk). If 
either appears the needle is removed and reinserted elsewhere. If 
neither appears, the syringe is screwed on the needle, the air with- 
drawn from the needle (it bubbles up through the fluid to the top 
of the syringe), and the piston pushed slowly down. The needle 
is removed and the puncture treated as for the intravenous in- 
jection. 

The inflammation following the burn is treated by rest and pro- 
tection; in other words, the treatment is simply a sensible appli- 
cation of the principles already discussed. The dressings are 
changed only often enough to keep them clean and aseptic. If 
granulation tissue becomes excessive, it is touched with silver 
nitrate in the stick. If there prove to be insufficient skin material 
to cover the denuded area, islands of skin are grafted on (see a text- 
book on surgery for method). If there be a tendency to deforming 
contractures, splints are applied and passive movements used. 

Frost-bite. — Inflammations due to frost-bite require the treatment 
outlined in the discussion of chronic inflammation. Thus massage 
and cold baths are used to reestablish the vasomotor control, and if 
necessary soothing ointments are applied to overcome the itching 
and other symptoms of nerve irritation. (For details of remedies 
used, see the section on Itching.) 

Cuts and other open wounds are treated by cleansing the ex- 
posed tissue with sterile water, or in running water, until every- 
thing that can be washed out by the water and blood is removed. 
Then if dirt is still present, hydrogen peroxid should be poured 
in and allowed to foam out in the wound, or, if the dirt be grease, 
gasoline may be used (where the parts are not very delicate or 
sensitive). 

As soon as we feel certain that we have removed all of the for- 
eign material, we proceed to cover the exposed tissues with a 
sedative but antiseptic dressing to protect the exposed nerves 
from further irritation and the tissues from contamination. This 
relieves some of the pain, but it may be necessary to apply either 
heat or cold locally, and even morphin hypodermically before the 
patient is quieted. As in burns, so here, an oily substance is more 
soothing than a rougher one, hence comes the popularity of 
greases among the laity. For small wounds we can follow this in- 
clination and apply phenolated camphor on a bandage. This is 



94 TREATMENT OF LOCALIZED INFLAMMATIONS 

made up of equal parts of phenol and camphor, and naturally is 
both antiseptic and sedative. It may be diluted with an equal 
amount of olive oil and still be sufficiently strong for most uses. 
Where the surface exposed is quite extensive, so that it is danger- 
ous to use an antiseptic on account of absorption, sterile bandages 
should be applied and the antisepsis obtained by means of the 
daily dressings, at which time the surfaces need to be irrigated 
with corrosive sublimate (1:1,000) or simple sterile water. 

In general, we may say that we apply moist dressings when we 
wish to produce a hyperemia to reduce the pain or overcome in- 




Fig. 12. 



-The Application of Heat to a Bruise or Strain bt 
Means op the High Candle Power Lamp. 



fection, and dry dressings in all other cases. For, as a general 
thing, bacteria cannot grow readily on a dry surface. It is for 
this reason that we sometimes shake a " dusting " powder over a 



INFLAMMATIONS OF THE SKIN 95 

wound, because it keeps the surface dry, preventing thereby the 
development of the bacteria already within the wound and also the 
accession to the exposed tissue of germs from the outside. 

Only in case of absolutely sterile wounds do we close up the 
wound with impermeable dressings, such as collodion or adhesive 
plaster. Because of the unresisted desire to close up wounds im- 
mediately we have the development of tetanus in the Fourth-of- 
July injuries and the development of deep abscesses in abdominal 
wounds. 

Bruises. — Bruises require chiefly the alleviation of the pain and 
the removal of the hematoma and detritus. The first is secured 
through rest and the application of heat; the second through rest 
and the promotion of hyperemia; therefore the use of rest and 
heat generally bring about the cure of the bruise. The heat is 
produced by the hot-air cabinet where that is available; other- 
wise moist bandages covered with oiled muslin, silk, or paper are 
used. To the solution used for moistening such bandages, methyl 
salicylate may be added, or, better, a fifty-per-cent solution of 
methyl salicylate in olive oil is rubbed over the bruised surface 
before the warm, moist bandage is applied. Such bandages are 
treated as poultices and changed when they become cold or dry. 

Abrasions. — Abrasions are treated practically as open wounds. 
But the underlying tissues are usually bruised, hence they often 
require antiseptic, as well as moist, dressings. For this purpose, 
the bandages may be moistened in 1 : 2,000 bichlorid-of-mercury 
solution (or iodoform, five per cent) before applying. Then, if 
there be considerable swelling and pain, a covering of oiled silk or 
muslin should be wrapped about the moist bandage. 

2. Bacterial Inflammations of the Skin 

The reaching and removing the cause of these inflammations is 
the point at which we usually fail, because the parasite, be it in- 
sect or coccus, usually lies underneath the stratum corneum of the 
skin. We must therefore either penetrate or macerate this layer 
before we can destroy the parasite. Furthermore, most of the skin 
parasites are propagated by eggs. We must, therefore, continue 
our treatment long enough to bridge over the interval until the 
eggs are hatched, or else use preparations strong enough to destroy 
8 



96 TREATMENT OF LOCALIZED INFLAMMATIONS 

the ova and spores, as well as the mature organisms. To meet this 
condition requires that the hair be pulled out whenever a hairy 
area becomes infected with a fungus or organism that can grow 
within the hair follicle and stalk. Finally, our treatment is very 
incomplete if it does not stop the irritation and pain caused by the 
organism. 

The standard drug for macerating the stratum corneum is sul- 
phur. This acts probably by being converted into the sulphids 
when applied to the skin, and these soften and thus make ready for 
removing with soap and water the horny layer. Of course the 
sulphur exerts some antiseptic influence on the parasites themselves, 
but the use of sulphur ointments without the vigorous use of soap 
and water is generally disappointing. 

Sulphur ointment is, according to the U. S. P., twenty per cent 
of washed sulphur and eighty per cent of benzoinated lard. 

Another drug that both penetrates the stratum corneum and 
attacks the parasite is naphthol. But naphthol is so toxic that 
only naphthol derivatives are used. Of these the best appears to 
be epicarine, and this is the drug we may use with our more fas- 
tidious patients who may have need of such vigorous treatment. 
It is applied in the form of a ten-per-cent ointment, using, if we 
desire to do so, even unguentum rosae as a base. Epicarine is also 
used in a five- to ten-per-cent alcoholic solution where the pro- 
longed application of the drug is not needed, as in case of the 
pediculi. The alcohol solution is very irritating to the inflamed 
skin, therefore it is wise to direct its dilution with water before ap- 
plying to any considerable area. 

Another useful drug is the ointment of ammoniated mercury 
(U. S. P.). This is more soothing than the others just mentioned 
and seems almost as effective. It is a ten-per-cent ointment in 
petrolatum and wool fat. 

The treatment of the inflammation itself follows closely the 
principles laid down in our general discussion of inflammations. 
The chief treatment is the production of hyperemia by means of 
the vacuum cup, constriction, heat, or poultices. Of the poultices 
the clay poultice is at present the most popular and the easiest to 
use. Its content of glycerin and methyl salicylate gives a sedative 
effect beyond that of the moist heat. 

Where it is undesirable to macerate the stratum corneum we 



INFLAMMATIONS OF THE SKIN 97 

should choose those drugs that pass the skin quickest, such as 
guaiacol, camphorated phenol, methyl salicylate, etc. The writer 
prefers to use guaiacol in a fifty-per-cent oil solution followed by 
the application of heat (thermophore), because its effect is both 
antiseptic and sedative. 

Of the astringents used in dermal inflammation, the zinc-oxid 
ointment is the mildest and perhaps most generally used. More 
antiseptic and stimulating is the ung. resorcini compositum, N. F., 
referred to above in our discussion of burns. This quality makes 
it generally useful in chronic conditions and where the tissues 
need stimulation. Still more vigorous is the Wilkinson's ointment, 
also called Hebra's itch ointment, and known officially as ung. sul- 
phuris co., N. F. 1 All these ointments are usually reserved for 
chronic and obstinate cases, especially those where it is impossible 
to produce hyperemia or use hydrotherapeutic procedures that 
tend to stimulate and control the circulation of the blood through 
the affected areas. 

The use of ointments and bandages provide the physiolog- 
ical rest called for in our discussion of general principles. The 
reduction of the swelling, etc., and the restoration of function 
are all best provided for by the hyperemia, and when these 
measures do not care for the pain, the application of guaiacol 
is usually sufficient for that, thus obviating the use of a systemic 
analgesic. 

The inflammations shade off gradually into nutritional dis- 
turbances, and we^ often have to treat obscure conditions to which 
we can hardly apply the term inflammation because of the absence 
of most of the cardinal symptoms, but which, because of their sim- 
ilar pathogenesis, must be treated along similar lines. When con- 
fronted with such a condition we must ask ourselves: Is the irri- 
tation from without or within? Is the process atrophic or 
hypertrophic in character? Is it the reaction of the organism to 
some stimulus or is it the direct effect of some outside force ? 

formula: 

Calcium carbonate 10 grams 

Sublimed sulphur 15 " 

Oil of cade 15 " 

Soft soap 30 " 

Lard ,..,.,,,., 30 " 



98 TREATMENT OF LOCALIZED INFLAMMATIONS 

If, now, it prove to be the action of an outside force, its 
treatment is the same as that of an inflammation, viz. : re- 
move the cause, protect the exposed tissues, and stimulate repair. 
But if it be a nutritional disturbance, such as the growth of 
a papilloma or wart, or the wasting of the skin, we must call to 
our aid other drugs to correct the deformity. Of such drugs 
arsenic holds the first place, because its dilation of the capillaries 
leads to a better nutrition of the tissues, and clinical experience 
has shown that epithelial tissues are preeminent among those bene- 
fited; hence, arsenic is always thought of for skin and nerve 
lesions. For its systemic effect, it is usually given as Fowler's 
solution in five- to ten-drop doses, otherwise it is given as the tri- 
oxid in doses of -gV to ^V grain. Frequently, in order to avoid an 
undesirable frequency of the dose, a slowly dissolving salt of 
arsenic is injected into a muscle. Of such salts we have the 
cacodylates, atoxyl, and arsacetin. Lately it is becoming cus- 
tomary to inject one of these salts every second or third day in 
the treatment of skin lesions that demand this quickening of the 
metabolic processes. 

Aside from its systemic effect, arsenic is useful in hypertrophies 
of the skin for its local caustic action. Thus, for epitheliomata it 
is the favorite caustic. For caustic purposes it is used in paste 
form, as, for instance, Marsden's paste: 

IJ Arseni trioxidi 1 part ; 

Pulv. acacias 2 parts. 

Another paste, less vigorous, is : 

Ty, Arsenous acid 1 part ; 

Charcoal 1 " 

Red mercuric sulphid 4 parts. 

Water sufficient to form a paste. 

The use of arsenic as a caustic causes pain, and therefore the 
11 cancer doctors " who use pastes all try to combine analgesics 
with the arsenic, and for this purpose try everything from cocain 
to creosote. 

For the inflammations caused by tuberculosis of the skin 



INFLAMMATIONS OF THE SKIN 99 

(lupus) nitric acid, or the acid nitrate of mercury, has proved to 
be the best caustic; apparently it forms a wall about the tissues 
through which the germs cannot penetrate. 

Atrophic nutritional disturbances in general call for stimulant 
applications, such as quinin, iodoform, etc. ; hypertrophic dis- 
turbances call for sedatives, such as oxid of zinc. 

In addition to such drug treatment we may use the high-fre- 
quency currents to influence skin nutrition. These act apparently 
by causing a stimulation of all the local vasomotor forces ; the skin 
feels warmer and moister and looks redder than before the treat- 
ment, hence we believe such treatments to be indicated in atrophic 
skin conditions, as, for instance, where the skin is dry and scaly, 
or where sluggish ulcers seemingly refuse to heal. This current is 
applied by means of vacuum glass electrodes for five to ten min- 
utes at a time. 

In all our discussion of skin inflammations, it must be under- 
stood that collections of pus, for example in case of boils, must 
be opened freely and drained. The cavity should be irrigated with 
an antiseptic, such as mercury bichlorid, or, if there be several 
pockets and recesses hard to reach, with hydrogen peroxid. The 
action of the latter is the more mechanical, of the former more 
chemical. 

We may here summarize the action of caustics by calling atten- 
tion first to the various degrees of caustic action : hyperemia, inflam- 
matory necrosis, and chemical solution. Second, the character of the 
scab (eschar) depends on the chemical action of the particular caus- 
tic. Thus the metallic caustics, as a general rule, give hard scabs, 
the alkalies give soft, and the acids hard. Thus silver nitrate forms 
a hard scab, carbolic acid a soft one, trichloracetic acid a hard one 
(carbonizing the tissue) ; so also nitric and sulphuric acids. The 
Vienna paste (equal parts of caustic potash and unslaked lime), 
London paste (equal parts of caustic soda and unslaked lime), 
and sodium ethylate all liquefy the tissue affected. Hence 
the latter are especially useful for removing horny growths 
(as warts), while the acids are better adapted to the softer 
ones. 

To illustrate a combination of synergists for caustic pur- 
poses, I give the following formula, recommended for soft 
warts : 



100 TREATMENT OF LOCALIZED INFLAMMATIONS- 

Chloral hydrate 6.0 grams. 

Acetic acid 6.0 " 

Collodion 15.0 " 

Salicylic acid 4.0 " 

Ether 4.0 c.c. 

Mix and paint wart once a day. 

It is usually, however, better to use the individual drug indi- 
cated and thus secure a better control of its action. 

IV. INFLAMMATIONS OF MUCOUS MEMBRANES 

Since mucous membranes contain such an abundance of secret- 
ing glands, they need, when inflamed, more frequent cleansing than 
does the skin. This is the more necessary because their very 
moisture makes them more attractive to bacteria. Then again, their 
permeability permits the penetration of bacteria and their toxins 
to the blood stream and body fluids, thus making constitutional 
what was originally a local disorder. This permeability renders 
necessary, also, greater caution in employing drugs for the relief 
of mucous disorders.. For instance, we might employ many tinc- 
tures of powerful drugs on the skin with little or no effect on the 
general system; but every such tincture, when employed for the 
mucosa, would bring about symptoms of intoxication almost at 
once. Mucous inflammations are also more painful than dermal 
ones, and require a freer use of sedatives, which, on the other 
hand, need not be as strong as those required for the skin lesions. 

In general, it is best that the irrigating fluids which we must 
use so freely on mucous surfaces should have the same chemical 
reaction as the normal secretions of the membranes themselves. 
Thus alkaline fluids should be used in the nose, faintly acid ones 
in the vagina and bladder, etc. Secondly, these irrigating fluids do 
less harm if nearly isotonic with the body fluids, for they then 
avoid blanching or congesting the tissues irrigated unless we should 
seek this very osmotic effect. 

The term " catarrh " is often applied to chronic inflammations 
of the mucous membranes, but in so far as there is any definite 
meaning to the term, it refers simply to the disturbed function, 
the abnormal secretion from the membrane mentioned. Ordinarily, 



INFLAMMATIONS OF MUCOUS MEMBRANES 101 

also, it means an inflammation in which the cell activity is too great 
rather than one in which it is too small. 

Another term often used in mucous inflammation is diphtheritis 
— referring to a false membrane of fibrin and leucocytes over the 
inflamed mucosa. This should not be confused with the disease 
entity known as diphtheria, in which such a membrane plays an 
important role. 

Here, as in skin lesions, atrophic conditions require stimu- 
lation and the hypertrophic sedation. Thus acute inflammations 
of the nose which incline toward turgescence and hypertrophy are 
generally irrigated with some soothing alkaline solution, while 
chronic atrophic inflammations are treated with vapors of tar, 
iodin, and other irritant antiseptics. 

Accessible Membranes 

In generalizing regarding the treatment of mucous inflamma- 
tions, we find it useful to separate them into two classes: the ac- 
cessible and the inaccessible. Now we can carry out the above 
principles when we treat accessible cavities, especially with refer- 
ence to irrigation — probably the most important part of the treat- 
ment. Thus for inflammations of the nose and throat we order 
the use of sprays several times a day to keep the mucosa free from 
detritus and to relieve the discomfort. This so completely meets 
the indications that in such inflammations we need to give little or 
no systemic treatment. The solutions for such alkaline irrigating 
fluids may be illustrated by the following formula: 

Sodii bicarb 3.0 grams. 

Sodii biborat 3.0 " 

Phenolis 1.0 " 

Glycerini 10.0 c.c. 

Aqua? q. s. ad 200.0 c.c. 

M. D. S. : Dobell's Solution. Add to a quart of water and 
use in an atomizer. 

The liquor antisepticus (N. F.) is another widely used formula 
for an indifferent fluid that may be used in many places and for 
many kinds of inflammation. 



102 TREATMENT OF LOCALIZED INFLAMMATIONS 

For chronic conditions and for acute conditions where there 
is great discomfort and tenderness, especially of the nose and 
throat, we prefer to irrigate the membranes first with an aqueous 
solution like the above and then follow it up with an oil spray to 
coat over and protect the inflamed area. The following formula 
illustrates a type of the oil sprays used: 

Thymoli gr. x ; 

Mentholis gr. xx ; 

Eucalyptol gtt. xx ; 

01. cubebae gtt. xl ; 

Benzoinol oz. vj ; 

01. rosas gtt. x. 

M. S. : Douglass' formula. 

Another type of accessible mucous surface is represented by the 
vagina. Here there are fewer nerve-end plates or sense organs to 
be considered, and as a consequence the patients tolerate less care- 
fully selected medication. Thus in a recent text-book the following 
solutions are recommended for vaginal douches: Alum (1 dram to 
1 pint), copper sulphate (-J dram to 1 pint), zinc sulphate (-£ dram 
to 1 pint), corrosive sublimate (1:3,000 to 8,000), phenol (1:30 
to 60), formalin (1: 1,000 to 6,000), permanganate of potash, thy- 
mol, hydronaphthol, boric acid, etc. Inasmuch as the membrane 
is faintly acid in reaction, and the chief value of the irrigation lies 
in its mechanical influence, we would prefer in the above list the 
solutions that would do the least harm from their chemical action, 
e. g., potassium permanganate and boric acid. The former may 
be used in solutions varying from 1 : 1,000 to 1 : 4,000, the latter in 
two- to four-per-cent solutions. 

The stomach presents another slightly differing type, for it is 
partly accessible to irrigation by the stomach tube, yet for the 
most part inaccessible, largely because physicians do not recognize 
the value of gastric lavage. The best solution for gastric lavage is 
pure water, but slight modifications are made by using, for in- 
stance, one fourth to one half per cent salicylic acid, or, when much 
mucus is to be dissolved, rather strong solutions of sodium bicar- 
bonate or other harmless alkali. 



INFLAMMATIONS OF MUCOUS MEMBRANES 103 

Inaccessible Membranes 

For the completely inaccessible membranes we must imitate the 
irrigation and give by the mouth solutions that will to some ex- 
tent at least cleanse the inflamed surface. Thus for enteritis we 
use mineral waters freely, choosing the less drastic and more seda- 
tive. For cystitis we use solutions of hexamethylenamin, but here 
we can also use in many of our cases direct irrigation; so it is 
customary to treat cystitis both by the mouth and through the 
urethra. 

In other respects than those which we have mentioned localized 
inflammations of mucous membranes are treated like those of other 
tissues and according to the general principles discussed above. 

Drugs Used in Mucous Inflammations 

Of the drugs most used in mucous inflammations, the following 
are the most important: Besorcin; this is practically a coal-tar 
derivative. It is both less irritant and less toxic than phenol, but 
more antiseptic; hence it is an excellent constituent for antiseptic 
washes. Resorcinol should not be confused with the proprietary 
article put out under that name. It is used for sprays in two- to 
four-per-cent solution and for ointments (skin) in five to thirty 
per cent. It is also given internally in doses of J to J grain. 

Bismuth subnitrate is used for gastric and intestinal inflamma- 
tions. It is sedative chiefly because it coats over and thus protects 
from irritation the denuded surface. It is slightly antiseptic. It 
is best given in suspension. 

Orthoform (methyl-ester of amido-oxybenzoic acid) is decid- 
edly antiseptic and anesthetic, but it is very insoluble and slowly 
absorbed, hence it may be added to powders (insufflation), oint- 
ments, or solutions to quiet the pain. 

Silver nitrate is given in gastric inflammation in J- to J-grain 
kaolin pills. It is used in one- to ten-per-cent solution for paint- 
ing mucous membranes to destroy the microbes and form a necrotic 
coat (eschar) over exposed tissue. 

Thymol is stimulant and slightly antiseptic. It is a phenol 
and shows the phenol action in paralyzing the end plates of the 
nerve. It is soluble in 900 to 1,000 parts of water, but freely in 



104 TREATMENT OF LOCALIZED INFLAMMATIONS 

alcohol and oils. It is used in five-per-cent alcoholic solution for 
the skin, but only in 0.5 per cent for the mucosa. 

Eucalyptol is less stimulant than thymol. It is eliminated by 
the skin or bronchi. It is irritant enough to give a warm taste. 

Tar is such a mixture of creosote, turpentine, acetic acid, etc., 
that its action varies at different times. It may even have a caustic 
effect. 

V. INFLAMMATIONS OF SEROUS MEMBRANES 

Since the cavities lined with these membranes can be reached 
only through the blood stream or by positive trauma involving 
other structures as well, their inflammations are usually parts of 
constitutional disturbances and rarely confined to the one mem- 
brane. The treatment also in only a small percentage of the cases 
can be local, but must seek to affect the inflamed area through other 
tissues and chiefly through the circulation. 

True, we can puncture the pleural sac or pericardium and as- 
pirate an exudate, but the operation is such that we hesitate to 
employ it except in case of real need. Hence, in order to . avoid 
such an operation and at the same time follow our principles and 
secure rest and better blood supply, we need to employ more gen- 
eral measures than we needed to use for the skin or mucosa. 

To secure rest for the serosa? it is practically necessary to put 
the patient to bed and forbid any unnecessary activity, and reduce 
even the excursions of the thorax and the movements of the heart 
to the minimum. Thus in pleurisy the chest is tightly bandaged, 
and in pericarditis the heart is slowed by the application of ice 
bags, both in addition to the bed rest, which in general quiets all 
the bodily functions. 

The local circulation has to be stimulated from the outside of 
the body by the application of heat or cold, and since so many tis- 
sues besides the serosa must be affected with the serosa, we succeed 
less well than with inflammations in more exposed situations. 

We secure antisepsis only by saturating the body fluids with 
our drugs, hence our success is always problematic. We do find, 
however, that hexamethylenamin may be demonstrated in the 
serous fluids, and also, to a somewhat lesser degree, salol. Hence 
these two drugs are used generally for their antiseptic effects in 
serous inflammations. 



INFLAMMATIONS OF MUSCLES AND TENDONS 105 

For the regeneration of the function of the inflamed cells and 
for the absorption of exudates we must depend upon stimulating 
the functions of the entire body. Hence we give nux vomica and 
cathartics, such as cascara or calomel, and potassium iodid in our 
cases of pleurisy ; for example, for their systemic rather than their 
local values. This point must be emphasized, because there is a 
tendency to laud drugs as specifics in serous disorders when the 
simplest reflection is sufficient to show the absurdity of the claims 
for limited local effects. On the other hand, the vigorous use of 
systemic treatment, either with drugs or hydrotherapy, or both, 
cannot fail to bring about an improvement in such inflammations. 

VI. INFLAMMATIONS OF THE MUSCLES AND TENDONS 

Inflammations of these tissues are usually either secondary or 
due to trauma, hence a bacterial inflammation limited to these 
tissues is rare, either at the inception or close, for the protected 
position as well as the character of the muscle tissue are inhibitory 
to bacterial growth. 

There are a number of disorders, however, that need a moment's 
discussion. Therefore, in spite of the obscurity that still sur- 
rounds the most of them, we shall mention them in this connection. 
In practically none do we find all the cardinal symptoms, and in 
most we find the characteristics of chronic rather than acute in- 
flammations. The treatment in general, then, is directed rather 
toward the relief of pain and the restoration of function than 
toward antisepsis or reduction of heat. 

Bruises. — So far as the muscles are concerned in contusions and 
bruises, the first indication is simply for rest. The carrying off 
of the detritus resulting from the injury is best obtained by the 
production of a hyperemia through the application of heat (ther- 
mophore) and gentle friction. Most of the pain in bruises is due 
to the injury to the skin, and the treatment of this has already 
been discussed. To prevent permanent contractures and to pro- 
mote the restoration of function, passive movements are added to 
gentle massage as rapidly as the tenderness and inflammations dis- 
appear. More damage is done possibly by too vigorous than too 
gentle treatment. It is well, then, to keep from making the tissues 
sore or red in carrying out such exercises. 



106 TREATMENT OF LOCALIZED INFLAMMATIONS 



Strain. — When tendons and muscles have been stretched beyond 
their normal powers of extension, it is essential for their recovery 
that they be kept in a state of absolute rest for a considerable 

length of time. In fact, such 
injuries require longer periods 
of rest than fractures of the 
bones ordinarily do. Bandag- 
ing the muscle tightly affords 
such rest and also seems to 
have considerable good effect 
in the way of relief. The local 
application of heat to produce 
a hyperemia gives both relief 
and aids tissue regeneration in 
that the increased circulation 
helps to rebuild (or replace) 
rapidly. .the injured cells. As 
soon as the skin shows the signs 
of the atrophy that results from 
the tight bandaging, or the 
muscles' seem in danger of the 
atrophy from disuse, massage 
and passive movements must 
be begun. This insures the 
growth of more elastic fibers in 
the regenerated tissue than 
would occur if the tissues were 
kept in just one position. Rare- 
ly should a muscle be bound 
more than a week without having the dressings removed and the 
surfaces rubbed and brightened up ; but to set any time limit for 
all cases is, of course, illogical and dangerous. 

Myalgia. — The pathology of this condition is not well under- 
stood. It is probably due to an accumulation within the con- 
tractile tissue of irritant products, either from without the body 
or from a breaking down of the normal tissue. The first thera- 
peutic indication is for the relief of the pain. Ordinarily this will 
yield to the application of heat and the administration of the sali- 
cylates. If it is severe, morphin may be needed to tide the patient 




Fig. 13. — Application of Zinc Oxid 
Adhesive Bandage for Muscular 
Strain and Myalgia. 



INFLAMMATIONS OF MUSCLES AND TENDONS 107 

over until the salicylates act. Sodium salicylate is given in fifteen- 
grain doses every two hours for eight doses, unless ringing in the 
ears appears before the whole eight are given. The local applica- 
tion of a fifty-per-cent oil solution of methyl salicylate (oil of win- 
tergreen) will prove very helpful and will have to be relied upon 
in case the stomach will not bear the sodium salicylate. An " im- 
proved " oil of wintergreen is " mesotan," which is diluted with 
an equal quantity of olive oil and rubbed in two or three times a 
day. This, like the oil of wintergreen, needs to be covered with an 
impermeable bandage, such as oiled muslin or paraffin paper, in 
order to secure thorough absorption. Most cases of myalgia are 
relieved by the application of the strong galvanic current, as well 
as by the use of considerable heat. If the incandescent lamp, or 
thermophore, be held over the surface, previously moistened with 
oil of wintergreen, it seems to have a very valuable effect in rid- 
ding the patient of pain and also in producing hyperemia, which in 
turn aids in removing the cause, in that it washes out the affected 
tissues. Of course, physiological rest is essential to the successful 
treatment of any myalgia. 

Since the deposit in the muscles of such irritant materials in- 
dicates a constitutional disorder, the treatment is not sufficient 
unless considerable attention be paid to the elimination of the irri- 
tants from the system and the stimulation of the nutrition of the 
body in general to insure a more perfect metabolism. Hence we 
give a prescription like the following, to be used for the several days 
succeeding the relief of the acute attack : 

^ Magnesii sulf atis 90.0 grams ; 

Tct. gentian, co 10.0 c.c. ; 

Potassii iodidi 10.0 grams ; 

Glycerini 40.0 c.c. ; 

AquaB 40.0 c.c. 

Sig. Dilute one teaspoonful in four ounces of water and drink 
one half hour before meals. 

Dystrophia. — This is a nutritional disturbance, at present still 
unconquered by medical research. The best that can be done for 
it is the stimulation of the nutrition of the whole body by elec- 
tricity and massage. The electricity can best be given in the form 



108 TREATMENT OF LOCALIZED INFLAMMATIONS 

of the sinusoidal current, using from 3 to 30 milliamperes for 
five minutes twice a day. The high-frequency current can also 
be used with the electrode to the affected muscles. This seems to 
have an especially strong stimulant action on the epithelial tissues, 
perhaps through the production of a hyperemia, perhaps through 
its stimulation of the nerves. It should be tried in every case of 
dystrophia. The application from three to five minutes daily would 
be advisable. 

Arsenic will also be found valuable for its systemic influence 
in these conditions. Whether it should be given in the form of 
Fowler's solution in from three- to ten-drop doses, or injected in- 
tramuscularly every other day in the form of arsacetin (twenty to 
twenty-five drops of a ten-per-cent solution) is a question that must 
be decided after the study of the individual patient. Its effect is, of 
course, simply general and nutritional, and in no wise specific. 

VII. INFLAMMATION OF THE BONES 

The bones suffer from bacterial attack, starting either in the 
marrow (osteomyelitis) or in the periosteum (periostitis). Their 
frequent fracture gives also an illustration of a traumatic inflam- 
mation. In the inflammation of bones, the cardinal symptoms of 
an acute inflammation are frequently all present, and with them 
comes the application of nearly all the general principles that we 
have mentioned. For instance, we find in nearly every case the 
need of relieving the pain, reducing the tumor, and restoring the 
function. 

The first therapeutic indication in case of a bacterial inflam- 
mation is, of course, rest ; usually complete rest in bed. If there is 
pus present, the abscess must be opened and drained. Then hyper- 
emia needs to be produced by the application of hot-air or vacuum 
cups until the diseased area is suffused w T ith good new blood. 

Drugs are usually of secondary importance. It may be neces- 
sary to give morphin at the beginning, pending the action of the 
local treatments. If the pus prove to be that of an organism for 
which we have a curative serum, this should be administered. If 
the general fever be high, the salicylates, salol or hexamethylena- 
min, are used for their systemic effect; but in general the stimu- 
lation of the systemic metabolism is attempted rather than the 



INFLAMMATION OF THE BONES 109 

specific medication of the diseased area. Thus we might prescribe 
mix vomica for its stimulant action, hexamethylenamin for its bac- 
tericidal power, acetanilid for its analgesic effect, and magnesium 
sulfate for its cathartic action, as in the following formula : 

1J Tct. nucis vomica? 10.0 c.c. ; 

Hexamethylenanrinaa 5.0 grams; 

Acetanilidi 3.0 " 

Magnesii sulfatis 20.0 " 

Elixir simplicis q. s. ad 180.0 c.c. 

Sig. One teaspoonful in water every four hours. 

Fractures (that is, traumatic inflammation) are hardly thought 
of as belonging to the department of therapeutics, because the set- 
ting of the bone and its consequent fixation in splints affords the 
condition necessary both for the relief of the symptoms and the 
restoration of function. Thus drug treatment is rarely needed, 
except to relieve the pain incident to the manipulation needed 
for restoring the bones to their proper relation. However, the 
restoration of function and the removal of debris resulting from 
the trauma are usually facilitated by gentle massage and passive 
movements, measures designed to stimulate the local circulation. 

Tuberculosis of the bones is notable because it produces no heat 
and very little pain. Hence tuberculous abscesses were long 
known as " cold abscesses " before the bacterial nature of the in- 
flammation was understood. The usual treatment is, therefore, 
simply to open wide and curette the cavities. But this treat- 
ment is so unsuccessful that tuberculous fistula? sometimes call 
for medical aid as well as surgical treatment, and the injection 
method suggested by Dr. Beck, of Chicago, is worth trying in 
every obstinate case. He injects these fistula? full of bismuth 
paste, and he finds that after a few injections the sinuses and fis- 
tula? close up and seem to heal out. In the older days a ten-per- 
cent solution of iodoform in glycerin was used, but this never 
seemed to heal the lesions as completely as the bismuth does. There 
are two formulae. The first, for the active cases, consists of 30 
grams of bismuth subnitrate with 60 grams of white vaselin, 
The mixture should be made and thoroughly stirred while boiling. 
The second formula, for quiet cases, consists of bismuth subnitrate, 



110 TREATMENT OF LOCALIZED INFLAMMATIONS 

30 grams; white wax, 5; soft paraffin, 5; and vaselin, 60. Either 
mixture should be injected with sufficient pressure to fill up all 
the interstices and folds throughout the diseased area. It is not 
very painful, and may be repeated in two or three days. 1 

In bone tuberculosis the use of the vaccine method of treatment 
is winning more adherents daily. The material used is one of the 
tuberculins, and the amount is selected according to the reaction of 
the patient. 

1 See Baer, Bulletin of Johns Hopkins Hospital, October, 1909. 



PAKT II 
REGIONAL THERAPEUTICS 



CHAPTER III 
DISEASES OF THE RESPIRATORY TRACT 

THE NOSE 

Rhinitis 

Acute Rhinitis (Coryza). — The nasal membrane seems pecul- 
iarly susceptible to influences from other parts of the body, hence 
its disorders are traceable to manifold causes. Thus simple nerv- 
ous excitement may produce in susceptible persons an engorgement 
with symptoms simulating those of a beginning inflammation. 
Similar nasal symptoms are found introducing attacks of such 
systemic diseases as measles and influenza. Finally, chemical and 
mechanical irritation, due to the exposed position of this mem- 
brane and the pollution of our atmosphere with smoke, dust, and 
other irritants, tends to complicate the therapeutic problem. 

Apparently the first process in acute rhinitis is that of conges- 
tion. The next is infection, and with it we have all the elements of 
the typical inflammation. 

If, now, we start our treatment while the rhinitis is a simple 
congestion, we have a chance of stopping its progress, of " abort- 
ing the cold." We seek first to produce a relative ischemia of the 
nasal membrane by withdrawing the blood to other parts of the 
body. Thus a hot foot bath with mustard in the water, hot drinks, 
a hot pack (sweating) all tend to send the blood to the parts where 
the heat is applied and thus deplete the nasal supply. If now in 
addition we blanch the mucosa of the nose by applying active 
astringents, we add to the force of our efforts and sometimes suc- 
ceed in averting an inflammation. In the first rank among such 
astringents stands adrenalin chlorid (1:1,000 solution), which 
should be applied with a swab or spray every thirty minutes until 
either the feeling of congestion and oppression disappears, or we 

113 



114 DISEASES OF THE RESPIRATORY TRACT 

give up our attempt at abortion and change to the treatment of the 
inflammation. 

As in all inflammations, so here, we should accord the inflamed 
membrane physiological rest. This demands that the patient keep 
away from irritating and changeable air; that is, that he stay 
in his room and breathe pure, cold air. This alone is sufficient to 
care for most colds. 

In addition to the above, the mucosa should be irrigated with 
antiseptic and soothing vapors or fluids. Thus sprays of simple 
alkaline aqueous solutions, or steam from such solutions, cleanses, 
soothes, and stimulates the repair of the inflamed cells. Such a 
solution may be made of sodium bicarbonate and sodium benzoate, 
of each four grains to the ounce. This may be used several times 
a day. 

Somewhat further along in the disease an oil spray, driven by 
compressed air or by a hand nebulizer, containing menthol and 
similar drugs, would be very grateful. 

If the secretions need to be checked, atropin may be used either 
in minute doses (g^o grain) frequently repeated, or as one or two 
doses of -gV to y^o grain. 

For the constitutional malaise an active cathartic with a coal- 
tar sedative will be quite sufficient. Thus a half grain of calomel 
and three grains of acetphenetidin every hour until relieved would 
be ample. For those who wish to give more drugs, we suggest the 
following prescription : 

^ Acetphenetidini 0.2 gram. 

Camphorae monobrom 0.1 

Caffeinas citrataa 0.05 ' ' 

Hydrargyri chlor. mitis 0.03 

M. f. chart, no. I. Da tales doses no. VI. Sig. One pow- 
der with hot water every hour until relieved. 

Or this: 

^ Pulv. doveri gr. x ; 

Quin. bisulph gr. v. 

M. f. chart, no. I. Da tal. doses no. III. Sig. One every 
four hours. 



THE NOSE 115 

To prevent the rhinitis from becoming chronic, the irrigation 
of the mucosa is the most important measure. While doing this, 
one should examine the passages to learn if there be hypertrophied 
turbinates, spurs, polypi, etc., which would keep up the inflam- 
matory irritation. Until such defects are removed, the mucosa 
cannot be thoroughly cleansed and kept in order. 

Chronic Rhinitis. — This may be due to repeated acute inflamma- 
tions, or to occlusions and hypertrophies, or even to the constant 
influence of irritants in the atmosphere. Prophylaxis plays a great 
role in dealing with this trouble, and therefore acute inflamma- 
tions, especially in children, should be thoroughly treated. Aden- 
oids, deformed palatal arches, and other causes of nasal catarrh 
should be carefully watched out for and treated. 

The treatment of chronic inflammation demands, first, the thor- 
ough and long-continued irrigation of the membranes, and sec- 
ond, the raising of the patient's constitutional resistance. 

The first is obtained by using in a good atomizer (such as the 
De Vilbiss) alkaline aqueous solutions twice or three times a day. 
The patient should be instructed to do this properly; i.'e., point 
the nozzle horizontally backward and move it about so as to cleanse 
out all the various cavities and recesses. Each treatment should 
be continued until the solution runs down into the mouth. Solu- 
tions such as the following are sufficient : 

^ Sodii bicarbonatis 5.0 grams. 

Sodii biboratis 5.0 " 

Sodii benzoatis 5.0 " 

Resorcini 2.0 " 

Glycerini 25.0 c.c. 

Aqua? 75.0 " 

M. f . inhalatio. 

The second is obtained by strengthening the vasomotor control 
by means of cold sponge baths, sleeping with the windows open, 
and the use of appropriate tonics. The washing of the face, neck, 
and thorax in cold water (beginning at 70° F. and lowering the tem- 
perature gradually from day to day) and following this with a 
brisk rubbing with a rough towel does much toward strengthening 
the circulation of the upper part of the body. After a while the 



116 DISEASES OF THE RESPIRATORY TRACT 

patient will be able to take cold tub baths (always of short dura- 
tion), and thus tone up the whole vasomotor system. 

The quality of air breathed has much to do with the condition 
of the mucosa of the air passages. Therefore every effort, es- 
pecially with children, should be made to keep this cold and pure. 
Warm and used-up air can only lead to mucous congestion and 
hypertrophy; that is, it weakens the circulation and dilates the 
capillaries. Hence sleeping with the windows shut and in warmed 
rooms is to be condemned. 

If the patient be anemic, have swollen glands, suffer from con- 
stipation, or have other constitutional disorders, these should be 
corrected as preliminary to the successful treatment of the catarrh 
itself. 

Epistaxis 

Nosebleed may be the symptom of constitutional disease, such 
as pernicious anemia or typhoid fever, or of irregular blood pres- 
sure following disorders of the ductless glands. Even vicarious 
menstruation would belong to this latter class. On the other hand, 
the hemorrhage may be due to the presence of nasal ulcers or 
varicosities. 

The first group requires, of course, constitutional treatment, but 
the temporary and local treatment is the same as for the local dis- 
orders. 

Ulcers should be touched with lactic acid (ten per cent to forty 
per cent) under the guidance of the eye. 

Varicosities and diffuse hemorrhage should be treated by the 
application of adrenalin chlorid applied on a tampon. Such a 
tampon should remain in place for thirty minutes to an hour. It 
should then be removed, and, if the bleeding be not stayed, a new 
one applied. 

To treat epistaxis without a speculum and the careful examina- 
tion of the mucosa is beneath the dignity of any well-trained 
physician, for every graduate nowadays has been trained in rhinol- 
ogy, and need not call in a specialist to clean out and examine the 
nares in case of hemorrhage. 

Syphilitic and leprous ulcers need, of course, medicines inter- 
nally as well as locally. 



THE THROAT 117 

Hay Fever 

Hay fever is a constitutional peculiarity and not entirely due 
to the condition of the nasal mucosa. A disordered condition of 
the latter, however, intensifies the trouble. Hence patients with 
hay fever should have the nasal membranes and passages put thor- 
oughly in order. Then, if the hay fever still persists, the only 
real relief is to keep away from the irritating pollen. The use of 
serums to overcome the intoxication gives still only temporary re- 
lief. Similar relief seems to be given by adrenalin. Both pollan- 
tin (q. v.) and adrenalin should be at hand for use by such hay- 
fever sufferers as cannot leave home at the pollen season. 



THE THROAT 

Pharyngitis 

Acute pharyngitis usually accompanies an acute rhinitis and 
shares in its treatment. Chronic pharyngitis is generally due to 
the irritation arising from changeable climate, sulphurous-acid gas 
and other irritants, from the smoke of factories and industrial 
plants, or the excessive smoking of tobacco. Because of its ex- 
posed position and the utter impossibility of removing all the 
irritants, chronic inflammation of the pharynx is practically in- 
curable. Relief, however, may be afforded by painting the mem- 
brane frequently with a caustic if the membrane be hypertrophic, 
and with a stimulant if it be atrophic. In the former case, silver 
nitrate in ten-per-cent solution is usually selected. In the latter, 
Lugol's solution may be used. Following such topical applica- 
tions, the spraying the membrane with oily vapor from a nebulizer, 
to coat over and protect the mucosa, will be helpful. Like chronic 
bronchitis, chronic pharyngitis may require a change of residence 
and great attention to the conditions of life for even moderate 
alleviation. 

Suppurative pharyngitis and peritonsillitis require, of course, 
free incision and drainage. Such incisions are made where the pus 
seems to be bulging out the membranes, but frequently the patient 
cannot open his mouth wide enough to give us a clear view of the 
field. Then the incisions are made through the faucial pillars ver- 




Fig. 14. — Position of Hand and Weapped Scal- 
pel fob Incising Peritonsillar Abscesses. 



118 DISEASES OF THE RESPIRATORY TRACT 

tically, about one fourth of an inch deep. To avoid too deep 
incision, the blade of the knife is wrapped with adhesive plaster 
up to the required distance from the point, and then inserted, pro- 
tected by the index finger. Free incision, even if the pus be not 
found, will prove beneficial. Ice is packed about the neck, or heat 

may be used if there is 
no danger from too free 
a development of pus. 
The throat is irrigated 
with cocain or menthol 
solutions to relieve the 
pain due to the tension. 
Sodium salicylate (fif- 
teen grains every two 
hours) or salol (five 
grains every hour) is given internally. Atropin is injected sub- 
cutaneously or given by the mouth until the throat feels its drying 
influence. Of course it may be necessary to give morphin by the 
needle to relieve the pain when it is intense. 

The bowels need to be kept free in both acute and chronic 
pharyngitis, and the use of cathartic sulphur waters for this pur- 
pose seems to be somewhat better than the ordinary alkaline 
cathartics. For available waters, the reader is referred to the sec- 
tion on mineral waters. 

The use of throat lozenges for relieving the discomfort of phar- 
yngitis is justified, although they do but little toward an absolute 
cure. The essential constituents seem to be benzoin, menthol, and 
some astringent (e. g., tannin). The following formula is an illus- 
tration of a harmless variety : 

Menthol gr. £%; 

Oil anise 1U -fa ; 

Benzoic acid gr. T V; 

Eucalyptol TTl tV- 

For one compressed tablet. 



Tonsillitis 

Because tonsillitis is a bacterial inflammation from the outset, 
it is accompanied frequently by constitutional depression out of 



THE THROAT 119 

all proportion to the gravity of the disease. We have then to 
stop the progress of the local inflammation, to prevent septicemia, 
and to eliminate the toxins. 

The local treatment for tonsillitis follows the general outline 
given for irrigating the mucous membrane of the throat, This con- 
sists in the application of ten-per-cent aqueous or even alcoholic 
solutions of resorcinol or the swabbing of the tonsil with camphor- 
ated phenol — measures which are sufficiently discussed in the 
treatment of localized inflammations of mucous membranes (q. v.). 

For the constitutional treatment, the first indication is that of 
stopping the pain, and the following ointment may be applied to 
the side of the neck to relieve the feeling of tension and irritation : 

Menthol 2.0 grams. 

Methyl salicylate 5.0 c.c. 

Camphor 3.0 grams. 

Lanolin 15.0 " 

Soft paraffin 10.0 " 

Or morphin in the usual dosage may be used by the mouth or 
subcutaneously. It is more usual, however, to use the coal-tar 
products internally to relieve the general distress, both to avoid 
the bad effects of the morphin and to secure the antiseptic and 
eliminant effects of the latter. Thus a dose or two of acetpheneti- 
din (five grains every two hours) will relieve the pain and enable 
the patient to take with greater comfort the aggressive treatment 
outlined below. 

For the systemic antisepsis, it is usual to give salol in doses of 
two and one half grains every hour ; or sodium salicylate, ten grains 
every two hours. This not only renders the intestinal tract some- 
what antiseptic, but also seems to have some effect on the body 
fluids in rendering them less useful as nutrient media. The sal- 
icylates have also a grateful analgesic effect that makes unneces- 
sary other treatment for pain. Calomel or a saline laxative should 
be used in connection with the salol, according to the condition of 
the bowel. The giving of calomel in J to \ grain with each dose of 
salol will frequently prove a satisfactory method of administering 
a laxative. 

A prescription embodying the above features would be the fol- 
lowing : 



120 DISEASES OF THE RESPIRATORY TRACT 

^ Phenylis salicylates 0.1 gram. 

Hydrargyri chloridi mitis 0.01 ' ' 

Sacch. lactis 0.2 " 

M. f. chart, no. I. Da tales doses no. X. Sig. One every 
hour during day. 

The above line of treatment is usually sufficient, but our dis- 
cussion would not be complete if we did not mention other usages. 
Thus the use of tincture of aconite in one-drop (every hour) doses 
to relieve the fever and headache has many advocates. We do not 
advocate this usage because it is less certain and more depressant 
than salol, etc. Besides this, it lacks the stimulant influence so 
desirable in this disease. Where one wishes, however, to use aco- 
nite and belladonna instead of the coal-tar derivatives, the follow- 
ing prescription might be substituted for the one given above. Its 
value lies in its power to reduce the sensibility of the sensory 
nerves, to send greater amounts of blood to the surface, thus reduc- 
ing the temperature and the feeling of oppression, and lastly, it is 
cathartic. 

5 Tct. aconiti 0.5 c.c. 

Tct. belladonna? 0.8 " 

Ext. colocynth. co 0.4 gram. 

Elixir simplicis 60.0 c.c. 

Sig. One teaspoonful every hour. 

Still another and more conventional prescription is the fol- 
lowing : 

^ Tct. aconiti 4.0 c.c. 

Sodii salicylatis 4.0 gram. 

Spts. setheris nitrosi 15.0 c.c. 

Syrupi aurantii florum 30.0 ' ' 

Aquae dest q. s. ad 90.0 " 

Sig. One teaspoonful every one or two hours. 

This prescription combines many features, which fact, of course, 
has made it popular. The aconite depresses the nervous system, 
the salicylate is antiseptic and analgesic, and the sweet spirits 
of niter is diaphoretic. On the other hand, the dose of aconite 



THE THROAT 121 

is too large and the sodium salicylate too small to meet our 
views. 

For those patients with whom we wish to use topical treatment 
rather than drugs much relief can be secured by utilizing the fol- 
lowing procedures. Thus considerable relief may be obtained by 
applying externally to the neck a Priessnitz bandage. This, as 
has already been explained, is a strip of cloth about six feet long 
and wide enough to reach from the angle of the jaw to the root of 
the neck. One third of the length of the bandage is wet in 
warm water, that end wrapped around the neck, and the dry por- 
tion wrapped over it. This tends to keep the moisture from evapo- 
rating and to produce a local hyperemia, with consequent relief. 

The cataplasma kaolini may be used for the same purpose as the 
Priessnitz bandage. This poultice is made up of the following 
ingredients : 

Kaolin 577.0 grams. 

Boric acid 45.0 ' ' 

Thymol 0.5 " 

Methyl salicylate 2.0 c.c. 

Oil of peppermint 0.5 " 

Glycerin 375.0 " 

This must be kept in an air-tight container and heated for use by 
setting the open container in hot water until it is warmed through. 
It is then spread on with a case knife to the depth of about one 
eighth of an inch thick all over the neck, from the angle of the jaw 
to the root of the neck and from the mastoid process on one side 
to that on the other. Absorbent cotton or clean gauze is then laid 
over the poultice and simply fastened in place with safety pins or 
similar appliances. 

It is, of course, very important to keep the stomach and bowels 
active during the course of tonsillitis, for the purpose of both 
eliminating the toxins and keeping up the patient's strength. Of 
cathartics calomel is the best, although magnesium sulphate is a 
good variant. Calomel should be used in the amount of one to 
two -grains daily in divided doses; magnesium sulphate should be 
given in solution; one dessertspoonful in three ounces of water 
morning and evening would be sufficient. 

The diet needs to be at least semiliquid and stimulating, thus 



122 DISEASES OP THE RESPIRATORY TRACT 

hot soups, beef extracts, custards, eggnogs, illustrate what is de- 
sirable. 

The prophylaxis of tonsillitis requires the cleansing of the 
mouth daily with hydrogen peroxid or some equally good cleanser, 
and the removal of the tonsils if they show hardening, hyper- 
trophy, or the deposit in the crypts of white masses. The same 
care that keeps the teeth in order tends to keep the pharynx free 
from inflammation. 

Laryngitis 

The general principles of the treatment for laryngitis are the 
same as those for tonsillitis. There is less liability, however, of 
the disease having in adults so prostrating a constitutional effect. 
Hence more attention perhaps needs to be paid to the local treat- 
ment and less to the constitutional, except in children, where spasm 
of the glottis and other reminders of croup must be prevented. 
With children, therefore, it is wise to use internally some active 
form of iodin, such as iodized lime (one grain every hour until re- 
lieved), or the burnt sponge (spongia combust a) of the home- 
opathic pharmacopeia, as well as the local treatment mentioned 
below. 

The local applications must be in the form of sprays or vapor, 
or else the solutions must be applied with a camel's-hair brush 
under the guidance of the eye by means of the laryngoscope. The 
most available treatment is the inhalation of steam charged with 
eucalyptol or resorcinol. This is carried out by the usual method 
mentioned in detail elsewhere. It affords us the desired irrigation 
plus the sedation of the irritated nerve endings. Adrenalin can be 
successfully used in this condition if there be a tendency to local 
edema and congestion, such as usually accompany such inflamma- 
tions. This may be applied with a swab or sponge in the form of 
the 1 : 1,000 saline solution, or may be sprayed over the throat in 
the form of an oil solution with chloretone (Parke, Davis & Co.) 
vaporized in a nebulizer. 

The patient must, during the inflammation, avoid irritating the 
throat membranes by talking, or by breathing irritant gases (e. g., 
tobacco smoke), or by exposing himself to sudden changes of tem- 
perature. In other words, here as elsewhere, the most important 
factor«for recovery is physiological rest. We therefore ask our 



THE THROAT 123 

patients to stay indoors and keep quiet for the forty-eight hours 
when the inflammation is progressive. 

If, on the other hand, the inflammation be chronic and there be 
a tendency to sclerosis, a spray of iodin and alcohol should be used 
to bring about an active hyperemia with a consequent regeneration 
of the tissue. A formula for such an application would be : 

Tct. iodin 120 HI ; 

Carbolic acid 120 1TL ; 

Fluid tolu soluble 1 f 5 ; 

Glycerin 1 f 5 ; 

Alcohol sufficient to make 3 f§. 

This should be vaporized in a nebulizer, preferably by compressed 
air, and taken as often as convenient; at least three times a day, 
for at least five minutes. 

The constitutional treatment, the " hardening " of the throat, 
and climatic changes should never be neglected in chronic laryn- 
gitis. Since these are thoroughly discussed elsewhere, we need 
only mention them here. Among such measures, we would put in 
the first rank the proper use of the voice, and it may be necessary 
to send patients to competent vocal instructors for exercises in 
breathing, speaking, and singing before we can cure their lar- 
yngitis. 

Spasmodic Laryngitis. — Spasmodic laryngitis is really only an 
exaggerated reflex to local or allied irritation, hence the treat- 
ment of croup and laryngismus stridulus resolves itself into a qui- 
eting of the reflexes. 

The first drug to be thought of is a bromid. Thus potassium 
bromid (ten to twenty grains given in solution) will, though some- 
what slowly, quiet these reflexes. While this drug is acting, we 
should apply hot compresses to the neck, supply steam medicated 
either with baking soda or vinegar, or use the fumes of burning 
stramonium leaves (or some similar herb containing one of the 
atropin bodies). The heat, of course, relaxes the spasm. The 
alkaline or acid vapor tends to fluidify the mucus. The atropin 
inhibits the sensory ganglia causing the disturbance. 

Potassium or sodium bromid should be kept in our emergency 
cases in five-grain tablets. For the emergency treatment of croup 



124 DISEASES OF THE RESPIRATORY TRACT 

these tablets should be given in plenty of hot water. If we have 
the time and prefer to do so, we may write a prescription, of which 
the following may serve as an example : 



IJ Potassii bromidi 5.0 grams. 

Magnesii snlphatis 20.0 ' ' 

Glycerini 20.0 c.c. 

Essentia pepsini 20.0 ' ' 

M. f. mist. D. S. One dessertspoonful every half hour until 
relieved. 

In this prescription the purpose of the magnesium sulphate, it 
is needless, perhaps, to point out, is to open the bowels. The glyc- 
erin usually is pleasant to the palate in cases of sore throat, and 
this tends to quiet the reflexes. The essence of pepsin is here 
chosen as the vehicle because it is stimulant to the digestive ap- 
paratus. 

Edema Glottidis 

Edema glottidis is also a reflex condition, and if seen in time 
may be handled by quieting the reflexes, as in croup. But if not 
seen until all the membranes are so engorged that they practically 
fill the passage, we must use mechanical means for keeping the 
lumen free. Thus we may intubate (see Diphtheria) if the instru- 
ments are at hand. If not, we*may take a knife and incise the pil- 
lars of the fauces and other projecting masses of membranes until 
the exudation of blood and serum frees the passage. Then, too, 
we may surround the neck with cold compresses and give the pa- 
tient pieces of ice to hold in the mouth. We may swab the con- 
gested membranes with adrenalin chlorid and spray the same down 
into the larynx. Finally, we may do a low tracheotomy (q. v.), 
and should never abandon a case as hopeless until we have done it. 



Diphtheria 

Diphtheria is an inflammation of the mucosa of the pharynx 
and larynx of specific bacterial origin and characterized by the 
formation of false membrane and by great constitutional intoxi- 
cation. 



THE THROAT 125 

Hence attention must be given to the local as well as the sys- 
temic treatment of the disease. 

Since the introduction of antidiphtheritic serum, we have a 
specific medication for diphtheria. This consists in the subcu- 
taneous injection of the blood serum of animals immunized to the 
diphtheria bacillus. 

Its action is that of neutralizing the toxins in the body fluids, 
hence it must be used before the toxins become fixedly united with 
the body cells of the patient, and it must be used in quantity suf- 
ficient to flood the patient's blood stream, and thus have an excess 
to neutralize additional toxins as they are discharged into the 
blood current. It has been found that small doses of the serum 
may sensitize the patient to the bacillary toxins; hence there is 
more danger of giving too little than too much of the serum. 

The initial dose is 3,000 units of concentrated serum. It should 
be injected in the back in the loose subcutaneous tissue near the 
angle of the scapula. The skin should be previously cleansed with 
hot water and soap and with alcohol. The site chosen should be 
pinched up between the thumb and forefinger and the serum slowly 
injected parallel to the body surface. The point of injection should 
be covered as soon as the needle is withdrawn with clean adhesive 
plaster or with collodion. Do not rub or massage the tumor 
formed. When a needle is not furnished with the serum, a 3 to 4 
c.c. glass syringe should be used. This should be boiled and thus 
thoroughly sterilized before using. 

Additional doses of 3,000 to 5,000 units should be used every 
four hours until the false membrane begins to peel or other symp- 
toms of recovery are manifest. 1 

In addition to the specific medication, stimulants and tonics 

1 Investigations by Fritz Meyer (Berliner Klinische Wochenschrift, June 28, 
1909; editorial comment, Medical Record, July 31, 1909) on the effect of diphtheria 
toxin and antitoxin upon the heart, demonstrate: 

1 . " Antitoxin, if administered early in sufficient doses, absolutely prevents 
the fall of blood-pressure." 

2. "If given later, but before the fall has occurred, it delays the onset"; but 

3. "If given after the pressure has once fallen, it is quite without effect." 

4. "Antitoxin given early in sufficient dose prevents myocarditis after the 
injection of toxin in any amount." 

Meyer states that large doses of antitoxin given early will eliminate cardiac 
complications and postdiphtheritic cachexia. He recommends 5,000 units as 



126 DISEASES OF THE RESPIRATORY TRACT 

need to be used, as each case may demand to keep up the patient's 
strength. Thus strychnin and digitalis should be given to keep 
up the cardiac action and respiration. Atropin should be used to 
relieve laryngeal or tracheal spasm, and nitroglycerin should be 
administered in case of sudden dyspnea. The doses of each may 
be studied from the accompanying table (Rotch) : 



Age. 



3 months. . 

6 months. . 

9 months. . 

12 months. . 

2 years 

3 years 

4-10 years 

10-12 years 



Tinct. 


Digitalis. 


Minim. 


^o 


to i 


-A 


to | 


i 


to 1 


I 


to 1J 


* 


to 2 


* 


to 3 


l 


to 5 


3 


to 8 



Strychnin. 



Grain. 
siooo to TooU 
T7T0U to 5 o 
70~0 tO ^oo" 
600 tO -syo 

irk to 

Too 



I 5 

to- J 

to 



Totf 



TOO tO 



6u 



Nitroglyc- 
erin (1 
per cent 
solution). 



Minim. 
tV to £o 
A to-fV 
■is to rV 



TV tO ^ 

rV to \ 

i to f 
\ to 1 



Atropin. 



Grain. 

70~OU tO 1500 

TToo tO ToolS 
750 to Tg-Q- 
TWOO to -500" 
TBTJ to YT5 

6 00 tO ?QQ 

75 o to -ris- 
Yoo" to ioo 



Locally, antiseptics and soothing vapors should be used from 
the beginning. Thus steam charged with lactic acid (two and one 
half per cent), acetic acid (vinegar), resorcinol or guaiacol, used 
either in a bronchitis tent or through a face mask, will be helpful 
in keeping the patient from choking up. This effect can be further 
assisted by injecting pilocarpin hydrochlorate (^ to ^ grain) hy- 
podermically to induce sweating and salivation. 

The throat should also be thoroughly swabbed out with Loef- 
fler's solution on a cotton wool swab. This solution is made up of 

Menthol 10.0 grams. 

Toluol 26.0 " 

Liq. ferri sesquichlorati 4.0 c.c. 

Alcoholis absoluti 60.0 " 

M. f. mist. Da in vitro nigro. Sig. Loeffler's solution. 

To apply such local treatment is difficult, and Osier recommends 
the following : ' ' The nurse should hold the child on her knees, well 



first injection, and when this is not promptly effective, 20,000 to 50,000 units at 
a dose. 

These doses conform with those of McCollum and other competent observers, 
who, recognizing the danger in giving too small doses to neutralize the toxins, 
advocate 5,000 to 40,000 units. 



THE THROAT 



127 



wrapped in a shawl, with its head resting on her shoulder. The 
nose is then held, and as soon as the child opens it mouth a cork 
should be placed between the molar teeth, ' ' and the treatment then 
carried out. This should be repeated every hour or two. When 
the nose is affected, it should be sprayed out with a strong atomizer 
(hold the tube horizontally) carrying Loeffler's solution diluted to 
twenty-five per cent. In fact, such thorough spraying (but re- 
peated at longer intervals) should be done in all cases in order to 
free the nasal passages of debris and prevent the upward spread of 
the infection. 

If the larynx becomes filled with the membrane, a tube must be 
inserted or a tracheotomy done. 

Intubation. — The idea of putting a tube through the larynx in 
case of laryngeal stenosis was presented by Bouchut in 1858. But 




v ^--— — 



Fig. 15. — Intubation Set — Tubes, Mouth Gag, Intubator, Extubator. 



Trousseau, then at his zenith, combated the proposition and it was 
not taken up generally, nor accepted by the Academy of Medicine 
in Paris, before which body Bouchut had laid his suggestions. 
Hence O'Dwyer, of New York, who in 1886 reported case histories 
10 



128 DISEASES OF THE RESPIRATORY TRACT 



and valuable results, is often credited with the introduction of the 
plan of treatment. 

The tubes used are so shaped that they fit into the larynx and 
maintain themselves in situ. They consist of a head, neck, body, 
and end. The head (see illustration) is expanded so that its over- 
hanging edges catch and hang on the false vocal cords. The nar- 
row neck fits in between the glottis muscles, which grasp it tightly. 
The swollen body fits just underneath the cricoid cartilage, and the 
pointed end reaches down into the trachea, its blunt point serving 
to make it easier of introduction. They are made of hard rubber 
or some noncorroding metal, such as gold or silver. 

These tubes are introduced by an instrument (called the intro- 
ducer or intubator) , which consists of a handle with a hollow shaft 
into which the mandrin of a tube fits. The parts are so arranged 

that as soon as the tube is 
in place it may be detached 
from its mandrin by push- 
ing on the lever on the 
back of the handle. 

In order to facilitate 
the removal of the tube, a 
thread is attached by an 
eyelet to its head, and the 
end of the thread fastened 
outside the patient's mouth. 
To keep the patient from 
biting the thread, it is 
slipped between two of the 
molar teeth. 

Another instrument 
(that for removing the 
tube) completes the essen- 
tial set, although a mouth 
gag is a necessary adjunct. 
The extubator is shaped 
like the intubator, but has 
hinged jaws which, when pressed against the sides of the tube's 
lumen, grasp it so tightly that it may be withdrawn. 

The patient is held upright before the operator. Young ehil- 




Fig. 16. — Intubation of the Larynx (CaillS). 



THE THROAT 



129 



dren have to be rolled up in a blanket so that they cannot use their 
arms. The operator puts his left forefinger (see Fig. 16) into 
the patient's mouth and pulls the tip of the epiglottis forward 
against the root of the tongue. The tube is passed in the median 
line along this forefinger until it reaches the epiglottis, and then, 




Fig. 17. — Technique op Intubation. (Caille, after Trumpp.) 



by raising the handle of the introducer, the operator directs the 
tube forward into the larynx. When the head of the tube reaches 
the level of the end of his left forefinger, the operator uses this 
finger to push the tube gently into place deeper in the larynx, at 
the same time, with the right hand, freeing it from the mandrin, 
and withdrawing the introducer. The threads are then passed be- 
tween the teeth and fastened to the patient's ear. 

Should the child not open its mouth readily, the operator must 
force it to do so by holding the nose. He then slips the mouth gag 
back into place the first time the child takes breath. 

While introducing the tube the threads are held by the third 



130 DISEASES OF THE RESPIRATORY TRACT 

and fourth fingers of the right hand. This prevents their being 
lost or bitten through. 

As soon as the tube reaches its place in the glottis, the patient 
is seized with a coughing spell, which, however, soon passes and 
the patient becomes comfortable. If the tube slips by mistake into 
the esophagus we have no cough, and notice that the patient swal- 
lows hard, and that this pulls on the threads held in the right hand. 

The expert operator needs only a few seconds to put the tube 
into place; hence the operation makes but little demand on the 
patient's strength. In this respect it has a great advantage over 
tracheotomy. 

The tube should be removed as soon as the danger of suffocation 
is passed; the sooner the better. After extubating, the physician 
must stand ready to reintroduce the tube should the glottis seem 
about to close up. He should watch for this contingency at least 
half an hour. In general, the tube rarely remains more than three 
or four days in place. If it is reintroduced, it should not be kept 
longer than one to two days without another attempt being made 
to take it out. 

If the tube cannot be removed by using the extubator in the 
same general way in which the intubator was used (remember to 
raise the handle sharply in order to direct the point forward into 
the trachea) and pulling on the threads, one can sometimes succeed 
by compressing the trachea from without. To do this, we press the 
trachea and larynx between the thumb and forefinger, and stroke 
upward, and then tap the lower end of the tube with the little fin- 
ger. As soon as the tube seems to give way, we thrust the right 
thumb and forefinger into the mouth and grasp the head of the 
tube as it emerges from the larynx (Trumpp). 

The accidents that may occur are (1) the passing of the tube 
into the esophagus, (2) letting it slip into the trachea, and (3) the 
decubitus resulting from the pressure of the tube on the delicate 
tissues. 

We have already spoken of the first. Rarely does it cause any 
serious trouble, for the tube can be immediately drawn back by the 
threads, cleansed, and reinserted into the trachea. 

The second accident can only rarely occur. When it does oc- 
cur, tracheotomy should be done at once, unless the child succeed 
in coughing the tube out before the operation can be done. 



THE THROAT 131 

The ulcer is most liable to occur in the front wall of the trachea 
where the lower end of the tube presses against it, hence the 
shorter the tube the less danger of the ulcer; but, on the other 
hand, the shorter the tube the more danger of the patient's cough- 
ing it out and thereby becoming asphyxiated by the recurring 
stenosis. The avoidance of the decubitus is to be accomplished 
chiefly by shortening the length of stay of the tube in the larynx. 
Hence we frequently try to remove the tube as soon as the tem- 
perature, pulse, and respiration indicate an improvement in the 
patient's condition, standing ready to slip it back if any signs of 
suffocation appear. 

Among other mishaps the following are worth mentioning and 
providing against: 

(1) The pushing of masses of the false membrane down into the 
trachea has happened several times; in one series in three and one 
half per cent of the cases of intubation recorded. In such cases 
tracheotomy must be done, unless coughing brings the mass out 
immediately. 

(2) The lumen of the tube may be filled with membrane. This 
rarely happens, because even large membranes may pass through 
the tube. When it does happen, the tube should be pulled out, 
hastily cleaned, and reinserted. 

In view of all these possibilities, whenever we intubate we 
should always have a skillful nurse or else remain near enough to 
care for these emergencies, should any arise. 

The tubes come, of course, in various sizes. O'Dwyer's set was 
as follows : 

No. I, for a child one year old. 

No. II, for a child two years old. 

No. Ill, for a child three to four years old. 

No. IV, for a child five to seven years old. 

No. V, for a child eight to nine years old. 

No. VI, for a child ten to twelve years old. 

While the tube is in place, the child can swallow only fluid or 
semifluid foods, such as custards, ice cream, eggs, etc. Swallowing 
is easier when lying rather flat, but varies somewhat with the in- 
dividual. 

Tracheotomy. — In threatened suffocation, and when intubation 
is not available, we still have recourse to opening the trachea below 



132 DISEASES OF THE RESPIRATORY TRACT 




Fig. 18. — Tracheotomy Tube. 



the larynx and inserting a tube from the outside. Such a tube is 
curved (see illustration) so that the head fastens outside the wound 

in the neck and the lower 
end reaches down into the 
trachea. It must be made 
of noneorroding material, 
such as silver or hard rub- 
ber. A metal plate is usu- 
ally fitted to the neck of 
the tube and into eyelets in 
this plate tapes are fas- 
tened, the ends of which 
are tied about the patient's 
neck. The tubes are usually furnished with obturators to facilitate 
the insertion. 

The opening is usually made in the anterior median line just 
below the cricoid cartilage. When time permits, the skin, super- 
ficial fascia, and anterior layer of the cervical fascia are carefully 
divided by a vertical incision extending to one half inch from the 
top of the cricoid cartilage, the veins and muscles pulled aside with 
retractors, and the tracheal fascia covering the isthmus of the thy- 
roid gland and the isthmus itself pushed downward and held with 
a blunt retractor. A sharp-pointed knife is used to puncture the 
trachea and then a blunt-pointed knife is used to enlarge the 
opening. Usually the first puncture is made in the lowest point 
and the enlargement made by a slit upward. As soon as the 
trachea is opened, the patient coughs out a considerable amount of 
membrane and detritus. As soon as this has been expelled, the 
tube is slipped into place and fastened with the tapes. 




Fig. 19. — Trocar-pointed Obturator for Tracheotomy Tube. 



Where time and the surroundings do not permit a careful dis- 
section, a tube fitted to a trocar-pointed obturator (see illustration) 
is simply thrust at the proper place into the trachea. In this pro- 



THE THROAT 133 

cedure, of course, we must expect some bleeding and injury to the 
tissues, but the final results often justify the hasty method. 

For either operation, the patient lies with a bottle or sand bag 
under the neck, so that the head is thrown far back and the front 
of the neck is in fullest extension. The patient's head must be in 
the median line; that is, the head straight. The skin of the neck 
is cleansed with soap and water and alcohol, as for any surgical 
operation. The tube is also boiled and kept in sterile solution until 
slipped into place. 

The cricoid cartilage serves as a guide for the higher tracheot- 
omy, in which the upper three rings are usually incised. The lower 
location has only the isthmus of the thyroid as a guide. Fortu- 
nately the high operation is usually sufficiently low to afford breath- 
ing space in diphtheria. 

After the tube is inserted, great attention is needed to prevent 
its becoming clogged. In fact, the inner tube should be removed 
every day and cleansed in an alkaline antiseptic solution. The 
physician himself should remove the outer tube frequently enough 
to be sure of its cleanliness. 

The tube should not be removed until the patient can breathe 
with the inner tube removed and the external opening of the outer 
tube closed with a cork; but, on the other hand, it should not be 
left in longer than absolutely necessary, because the voice may be 
impaired if it is left too long. 

The operation is usually done without an anesthetic. It there- 
fore requires good assistance and a sure hand. In order to facili- 
tate the incision of the trachea, a tenaculum is hooked into the 
cricoid and kept there until the tube is safely in place. Failure to 
observe this precaution has caused the puncturing of the back wall 
of the trachea, as well as injuries to the tissues on either side. The 
hemorrhage may be severe, but usually stops of itself as soon as 
the venous engorgement caused by the dyspnea is removed by the 
freer respiration. Should the coughing caused by the opening of 
the trachea not cease promptly, a few drops of cocain may be 
swabbed on the mucosa of the trachea. 

It is well to have a rubber bulb with a tube to fit the tracheot- 
omy tube always ready to suck out the membranes or detritus if 
the tube become clogged. Of course, one should be careful not to 
pump air into the trachea in the hurry of using such a bulb. The 



134 DISEASES OF THE RESPIRATORY TRACT 

nurse should be at hand to wipe away the discharge from the tube 
as fast as it is expelled, and since the discharge is highly infec- 
tious, it must not be allowed to dry or reach anyone's clothing. 
It is best, therefore, to keep carbolic-acid solution on hand and 
keep the wiping cloths saturated therewith. 

The diet during the height of an attack of diphtheria is almost 
necessarily limited to water and thin liquids. As soon as conva- 
lescence sets in, broths, milk, etc., should be added as rapidly as the 
patient can swallow them. 

Prophylaxis. — All children exposed to the disease should be given 
an immunizing dose of antitoxin, varying from 500 units for a child 
under two years to 1,000 units for older children. 

Paralysis. — Diphtheritic paralyses are best treated by simple rest 
and good nourishment. 

THE BRONCHI 

Bronchitis 

Acute Bronchitis — Here we find an inflammation due to (1) 
weather changes (physical causes, such as chilling), (2) irritating 
gases (chemical causes), or (3) the invasion by bacteria, as after 
a rhinitis or in the course of the bacteremia ; or to a combination of 
all three. The inflammation is one of the mucosa of the bronchi, 
with a tendency to spread downward if unchecked, even to the 
alveoli, and thereby produce a broncho-pneumonia. After the first 
shock of beginning inflammation, with its irritant dryness, is passed, 
the reactive discharge into the lumina of the bronchi occurs, and 
this in turn may form such large masses of fibrin and leukocytes, 
with the ever-present bacteria, that the bronchi become practically 
occluded as with plugs. The patient would then suffer from want 
of air. Again, the smaller bronchioles may be so contracted by the 
reflex spasms from the irritated mucosa as to shut the alveoli .off 
from the access of air. Hence we have to do with a local inflam- 
mation and its consequences rather than a systemic intoxication 
such as we have, for example, in lobar pneumonia. 

The treatment is also mainly local. We seek first of all to re- 
lieve the bronchial membranes from physical and chemical irrita- 
tion by putting the patient to bed in a light, airy room with pure, 
cold air to breathe. The temperature of the room should be kept 



THE BRONCHI 135 

even and rather low; that is, between 60° and 65° F. Draughts 
must be avoided by using screens, but the windows must be kept 
open. It is better to have no artificial heat at all than to have 
sulphur, charcoal, or other fumes, for the patient can be kept warm 
enough even in a cold room under the bedclothes. 

Secondly, we seek to better the quality of blood supplied to the 
bronchial mucosa by inducing a pulmonary hyperemia. In weak 
subjects we do this by applying hot packs to the chest and back (of 
course taking precautions to prevent chilling during the proce- 
dure). In robust patients we apply fomentations, alternating the 
heat and cold. This latter procedure is quite stimulant and needs 
to be carefully supervised. 

Next we seek to cleanse the inflamed mucosa by supplying anti- 
septic moisture. This we accomplish by causing the patient to 
inhale steam charged with volatile oils, and it is best brought about 
by erecting over the patient's bed a bronchitis tent and letting the 
steam from a boiling kettle discharge into this space. 

To make the tent, we place rods from the head to the foot of the 
bed about three feet above the patient, one on each side, and a cross 
rod about halfway down the bed. Sheets are hung over these rods. 
The front side is sometimes left open for the better observation of 
the patient. The steam is best generated at some distance from the 
patient, to avoid vitiating the air he breathes, and conveyed within 
the tent by a rubber tube. 

The steam is charged with oil by pouring enough of the latter to 
form a film over the surface of the water in the kettle. Because it is 
somewhat more sedative, oleum eucalypti is generally used at the 
beginning of the attack, and when the secretion is more profuse, or 
greater stimulation is needed, it is replaced by oleum terebinthinae. 
Alkalies vaporized in the steam have a tendency to fluidify the 
sputum by stimulating the activity of the mucous cells. 

Finally, we give such drugs as may be needed to (1) keep the 
bowels open, (2) the vasomotors under control, and (3) the secre- 
tions antiseptic. For the first, calomel and the salines are pre- 
ferred; for the second, strychnin and camphor serve well; and 
for the third, hexamethylenamin renders us good service. The com- 
bination of drugs has to be changed from day to day, because of 
the need one day of quieting the reflexes, the next of stimulating 
them, etc. 



136 DISEASES OF THE RESPIRATORY TRACT 

The patient's chief complaint is usually discomfort, or even dis- 
tress, in breathing. This may be due either to reflex contractions of 
the bronchioles (asthma), or to the accumulation of exudates in the 
passages, the accompaniments of the so-called moist stage. The 
first is relieved by some vasodilator, such as atropin, which para- 
lyzes the peripheral ganglia ; or the nitrites, which dilate the capil- 
laries more centrally. Atropin is given in doses (adult) of -j-J-q to 
-gV grain, best with a needle, as needed. Amyl nitrite is inhaled by 
breaking under the nose (in a cloth) a pearl containing three 
grains. Nitroglycerin is given by the needle in -fo of a grain. The 
fumes of burning stramonium leaves and potassium nitrate are 
sometimes used, especially for children. (Prepared according to 
the directions given in our discussion of bronchial asthma below.) 

The second cause of dyspnea may be removed by giving stimu- 
lant expectorants. The simplest is the use of hot drinks. Thus 
often when giving the patient his morning cold rub, by simply 
giving a cup of hot milk or chocolate, one can excite an expulsive 
cough sufficient to clear the passages for several hours. Next come 
ammonium carbonate, ipecac, and apomorphin. Thus one might 
use the following conventional prescription: 

IJ Ammonii carbonatis 2.2 grams. gr. xl ; 

Vini ipecacuanha? 2.2 c.c. TTt xl ; 

Tct. nucis vomica? 3.0 " TTt 1 ; 

Tct. gentianse composite 12.0 ' ' 3iv ; 

Glycerini 

Aquae aa q. s. ad 240.0 " o v iiJ- 

M. f. mist. Sig. One to two tablespoonfuls every four hours. 

Or, better, because simpler and more direct in its application, the 
following : 

5 Apomorphin. hydrochloride . 0.02-0.04 gram. gr. J-f ; 

Acidi hydrochlor. dil 0.05 c.c. gtt. viij ; 

Aq. destill 150.0 " gv. 

Sig. One tablespoonful every two hours. 

When the vasomotor tone becomes lowered, as is shown by the 
coldness of the extremities, irregularities of the pulse, etc., it is 
well to introduce camphor subcutaneously in the ten-per-cent oil 



THE BRONCHI 137 

solution. This requires some four hours to take effect and should 
be introduced at the first sign of need, in doses of 2 c.c., repeated 
every six hours. Or, one may use caffein and sodium benzoate in 
doses of one to two grams subcutaneously for the same purposes. 
When this failure of the circulation occurs it should arouse a sus- 
picion of preceding circulatory disease. Consequently our therapy 
should be directed toward remedying this condition also. 

The cough of bronchitis fulfills a useful purpose and should be 
checked only when it exhausts the patient or prevents sleep and 
rest. Therefore cough sedatives (opiates) should not form a part 
of the routine prescriptions, but should be given separately and 
only as demanded. Thus heroin ( T V grain) may be given just 
before bedtime to insure the patient's falling asleep. In giving 
opiates we need always to remember their effect on the secretions, 
and overcome this effect by extra amounts of cathartics and other 
eliminant drugs. An illustrative prescription for a cough sedative, 
to be given as needed, is the following : 

^ Heroini 0.05 gram. 

Fl. ext. cascarae sag 0.3 c.c. 

Tct. gent, co 15.0 " 

Glycerini 20.0 " 

Aquae dest q. s. ad 45.0 ' ' 

Sig. One teaspoonful one half hour before bedtime. 

If, on the other hand, there is lack of productive cough — if the 
inflamed area remains obstinately hard and dry — then potassium 
iodid, two grains every two or three hours, will assist in hastening 
the catabolic process and in " loosening the cough." 

The diet during attacks of acute bronchitis should be chiefly 
fluid, but rather stimulant. Thus hot soups, meat broths, kefir or 
yogurt, lactone, buttermilk and eggnogs, are better than the neutral 
fluids used in intestinal disorders. The stomach should never be 
overloaded, and therefore the three-hour interval between feedings 
should be chosen. 

Broncho-pneumonia. — Broncho-pneumonia is essentially an ex- 
tension of acute bronchitis into the alveoli. Its pathology is the 
same, therefore, as that of bronchitis, with the addition that some 
of the breathing space (alveoli) of the lungs has been put out of 



138 DISEASES OF THE RESPIRATORY TRACT 

commission. We have to watch out for and guard against (1) ex- 
tension of the local process, (2) exhaustion of the heart in its 
effort to provide aerated blood, (3) exhaustion of the systemic 
strength because of coughing and other complications (e. g., gastric 
and intestinal or systemic toxemia), and (4) suffocation. 

First of all there is necessary pure, cold air and even (65° to 
68° F.) temperature in the sick room. What has already been said 
on this matter in our discussion of bronchitis applies also here. 

Next the air of the room must be rendered moist and charged 
with soothing and antiseptic vapors from a bronchitis kettle. With 
children (and broncho-pneumonia is particularly a children's dis- 
ease) this form of treatment is the principal one, because it is so 
difficult to secure the cooperation of children in taking medicines 
and treatments. The same general principles apply as in bron- 
chitis : that eucalyptol and turpentine be the chief drugs for medi- 
cating the vapor. Greater stimulation can be secured by means of 
ammonia and its fumes. Yeo advocates the addition of bicarbonate 
of soda to the steaming water to make it alkaline, and thus more 
effective in loosening the exudate from the walls of the respiratory 
passages. To summarize: At the beginning of the attack, use a 
bronchitis tent with oleum eucalypti; as soon as the secretions be- 
come more abundant, substitute oleum terebinthinre ; if there is still 
clogging of the passages, add ammonia to the alkalinized steaming 
water, or to gauze pads held before the child's face. Ammonia 
may be given internally also, by giving it as the aromatic spirits in 
doses of one teaspoonful well diluted. This cares for the first 
indication. 

We must relieve the heart as much as possible, and the use of 
Henoch's cold pack will assist in this: A cloth is wrung out in 
water at 50° to 60° F., folded several times, and wrapped about 
the thorax. This is covered with dry cotton or muslin and held in 
place with a binder. As soon as it becomes warm (say in twenty 
to thirty minutes), it is replaced by another cold compress. This 
draws the blood to the surface and relieves the engorgement in the 
smaller circulation. This procedure, of course, would hardly ap- 
ply for use with the aged, but is particularly good for children. 

When, in spite of this, the heart seems overburdened, we should 
begin to use our digitalis freely. (See note on digitalis, p. 417.) 
Camphor and caffein subcutaneously may also be used, the former 



THE BRONCHI 139 

for nervous excitement and vasomotor weakness, and the latter as 
a more general tonic. Strychnin is comparable to alcohol in this 
disorder, and should be used in emergencies to stimulate the spinal 
centers, and more generally to stimulate the digestive tract. 

In emergencies emetics may be used to excite a cough, but their 
weakening influence forbids their continued use. Thus Dover's 
powders in doses varying from J to 1J grains may be given to chil- 
dren from three months to five years of age, with \ to 2 grains of 
ammonium carbonate in a little syrup and water once or twice in 
twenty-four hours (Yeo). For older patients, the following pre- 
scription has been recommended : 

5 Ammonii carbonatis gr. v ; 

Ammonii chloridi gr. x ; 

Vini ipecacuanhas nx v ; 

Infusi senegas §j. 

To make one dose. Such a dose may, in cases of need, be re- 
peated three or four times in twenty-four hours. 

Of course apomorphin may be resorted to, but it is depressing 
and should be combined with stimulants whenever given. 

The excessive cough can, of course, be relieved by an opiate, 
but the medicated inhalations should be relied upon to allay the 
bronchial irritation, in order to avoid the depressing effect of the 
opiates. 

The gastrointestinal tract should be kept active both for its 
value in keeping up the patient 's strength and to prevent its push- 
ing up the diaphragm and crowding the breathing space. The use 
of carbonated alkaline waters and calomel should be continued 
throughout the disease. Diarrhea should be controlled by enemata 
(saline), tannalbin, and the avoidance of fermentable foods. 

For lividity and other signs of collapse, oxygen, electricity, hy- 
podermic injections of strychnin and apomorphin, should be used, 
the last to start up coughing or vomiting, and thus reestablish the 
aeration of the blood. The drugs may be assisted in this effort by 
the stimulant action of hot and cold packs to the chest and ab- 
domen, as recommended elsewhere. 

The diet must be of the simplest : milk, broths, albumen water, 
eggnogs, etc. Cold water should be drunk freely. 



140 DISEASES OF THE RESPIRATORY TRACT 

Chronic Bronchitis. — The chronic bronchial catarrhs are espe- 
cially prevalent in Great Britain (Yeo) and in the cities of the 
United States. They are due partly to the unfavorable meteor- 
ologic conditions (changeableness, etc.) and partly to the presence 
in the air of great quantities of irritant gases (e. g., sulphurous 
acid), and helped into being by the ever-present bacteria. Gener- 
ally speaking, then, the inflammation is due to chemical and 
physical irritation, more or less complicated by the presence of 
bacteria. The presence of the latter and their effect on the bron- 
chial membranes usually determine the character of the sputum, 
whether putrid and abundant or thin and scanty. 

The indicated treatment is naturally — what is most difficult 
to secure — a change of residence to a climate more favorable and 




Fig. 20. — Respirator (to be fastened over the nose). 

an air more pure. Simple trips to the mountains, or sea voyages, 
may help the disorder, but permanent relief can only be obtained 
by a permanent change. 

Even with a change of residence, sufficient treatment to clear 
up the existing inflammation is usually necessary. The first object 
of such treatment would be to check the inflammation and the sec- 
ond to restore the tissues to as good condition as possible. 



THE BRONCHI 



141 



The first is obtained by the use of antiseptics and hyperemia 
(the former are given by inhalation), the second by breathing exer- 
cises and hydrotherapy. Thus sending a patient into the pine 
forest, where the air is pure and the meteorologic conditions favor- 
able, and providing him with a respirator or turpentine pipe, usu- 
ally succeeds in checking at least the bacterial growth. These prin- 
ciples are followed, for instance, in the sanatoria of the Bavarian 
Alps with great success. 

The respirator is made of perforated zinc or hard rubber, to fit 
over the nose, and contains a sponge that is kept moist with tur- 
pentine. It needs to be worn practically all the time. 

The turpentine pipe consists of a glass bottle with two tubes, 
as shown in the illustration. The bottle contains warm water, on 
which floats a film of turpentine. The patient should carry this 
about and " smoke " it the greater part of the day. 

The turpentine is chosen because it is both stimulant (i. e., 
slightly irritant) and antiseptic, when carried in finely divided 
form, to the mucosa of the bronchi. 
It thus fulfills well the conditions 
demanded for the first part of the 
treatment. 

The hydrotherapeutic measures 
consist in alternating douches, hot 
and cold fomentations, the drip 
sheet, etc., all measures to stimu- 
late a more rapid flow of blood to 
the parts treated. The " wechsel- 
douche " may be played on the 
back and chest for five minutes 
a day, giving rapid interchange 
of temperature from 70° to 60° F. 
and from 120° to 110° F. Where 
this apparatus is not available, 
the hot and cold fomentations, one 
day to the back, the next day to 
the front of the chest, would do 

fairly well. After either of these procedures, the skin should 
be dried with brisk friction and the patient made to rest for 
an hour. 





i 


' 


^^ 


^— 


~ j- 


~ == ~~ Wi 




j r \ 




iil 


i 


'1 

6L, 





Fig. 21. — Turpentine Pipe. 
(a) Water; (6) turpentine. 



142 DISEASES OF THE RESPIRATORY TRACT 

Drugs may be used internally to approximate these same re- 
sults, but their success is but indifferent. Thus guaiacol and am- 
monium carbonate may be given in the following prescriptions : 

^ Creosoti 

Olei terebinthinae aa TTt xvj ; 

Glycerini gj. 

M. f. mist. Sig. A teaspoonful in hot milk t. i. d. 

IJ Ammonii carbon 

Sodii bicarbonatis aa gr. xl ; 

Spts. chlorof ormi TIX clx ; 

Infusi senegae ad gviij. 

M. f. mist. Sig. Two tablespoonfuls in hot water every five 
to six hours (Yeo). 

A formula for an inhalation that may be used instead of the 
simple turpentine is the following: 

IJ Thymolis 3 j ; 

Acidi carbolici 3ij ; 

Spts. chlorof ormi §j. 

M. f. inhal. (Whitla.) 

Of course other balsams and essential oils may be used, should 
turpentine, thymol, and carbolic acid prove distasteful to the in- 
dividual, but our success has been best with the turpentine. 

During the treatment for chronic bronchitis, the patient should 
be put on an extra strong diet similar to those mentioned for 
phthisis (q. v.) and made to live out of doors, best in a forest re- 
gion free from the dust and smoke of the cities. 

In addition, the use of mineral waters to stimulate the digestive 
tract has sometimes proven worth while. Of these waters, those 
charged with sulphur seem the most successful. 

When cavities have been formed (bronchiectasis) the treatment 
is similar but usually more vigorous. In particular, the regular 
emptying of the cavities by means of emetics (in small doses) must 
be cared for : for instance, apomorphin and fluid extract of ipecac, 
the former in one tenth grain, the latter in ten- to fifteen-drop 
doses, every morning before breakfast. Sometimes the morning 
cold bath, followed by hot drinks, is sufficient to produce this result 



THE BRONCHI 143 

without recourse to the nauseant emetics. At any rate, the effort 
should be made to obtain the result without them. To this end, the 
patient should lie every morning with hips high and shoulders low 
to promote the flow of the contents of the cavities into the bronchi. 
This usually brings on an expulsive cough, and the whole mass of 
exudate is ejected out of the mouth. 

Bronchial Asthma 

Asthma may be caused by (1) cardiac weakness, (2) hysteria 
or other neuroses, (3) by reflex irritation — e. g., from the nose, and 
finally (4) by chronic bronchitis. The treatment of the former 
types has been mentioned in our discussion of symptomatic therapy. 
And since the underlying disorders must be corrected by the appro- 
priate therapy, and this is discussed in the appropriate sections, 
therefore only the last type requires mention here. 

This is one of the most exasperating and obstinate affections 
with which the physician has to do. Probably the greatest relief may 
be obtained in the dyspneic attacks in the course of chronic bron- 
chitis by the intravenous injection of 10 to 120 drops of adrenalin 
chlorid in 1 : 1,000 dilution. This raises the blood pressure tem- 
porarily, and, whether by stimulating the right heart or by toning 
up the bronchioles, at any rate brings relief for considerable time. 
The injection may be repeated with impunity within an hour or so. 
The symptomatic treatment follows the lines of the popular use 
of the atropin group. Thus the dried leaves of the jimson weed 
(stramonium) may be smoked, or powdered belladonna mixed with 
a cubeb compound and smoked as a cigarette. A convenient for- 
mula for such a preparation is the following (Thornton) : 

Hyoscami foliorum 0.60 gram. 

Belladonnae foliorum 1.20 ' ' 

Stramonii foliorum 1.20 " 

Pruni virginianae foliorum 0.60 ' ' 

Potassii nitratis 0.60 " 

Aquae q. s. ad 15.00 c.c. 

Directions. — Dissolve the potassium nitrate in the water, 
moisten the leaves, roll into ten cigarettes. Smoke or burn on a 
plate three to four for relief of asthma. 

The interval treatment is that of the bronchitis. 
11 



144 DISEASES OP THE RESPIRATORY TRACT 

THE LUNGS 

Emphysema 

This is a mechanical rather than an inflammatory change. It is 
caused by compensatory or other efforts to force air out of the 
lungs while the vesicles are distended; hence prophylaxis is of 
greater importance than treatment, for the condition, once estab- 
lished, cannot be removed. All that the physician can do is to 
guard against and treat the various inflammations to which the 
condition is liable. 

Of these, bronchitis is chief, and is, in fact, an almost constant 
accompaniment of the condition. The principles laid down in our 
discussion of chronic bronchitis must govern here, also. First, the 
patient must live, if he is to have a tolerable existence, in an equable 
climate, such as Egypt, Porto Rico, or California. Second, he 
must avoid great exertion. Third, he must be temperate in all 
his habits. 

For the treatment of acute attacks and exacerbations, the 
breathing of compressed air (pneumatic cabinet) and the inhala- 
tion of bronchial sedatives, with the administration of morphin, 
will have to be resorted to. It will often be found necessary to 
stimulate the right heart with digitalis. 

Edema 

Edema is essentially a overflow of blood from the pulmonary 
vessels. It may be caused by an increase in blood pressure in the 
pulmonary circulation, due, for instance, to failure of the right 
heart, or to a weakness in the vessel walls, so that an ordinary blood 
pressure proves too great for them. At any rate, the blood serum 
leaks into the lung tissue. 

The treatment therefore consists in relieving the local high 
blood pressure. The most effective method is to remove 200 to 300 
c.c. (6 to 10 oz.) from a vein. (See Phlebotomy.) 

Next we seek to stimulate the contraction of the vascular walls 
by using intravenously ten drops of a 1 : 1,000 solution of adrenalin. 

If bubbling rales indicate the presence of considerable fluid in 
the air passages, diffusible stimulants (e.g., aromatic spirits of 
ammonia) should be used in teaspoonful doses frequently repeated. 



THE LUNGS 



145 



Should the patient recover from the first attack, the underly- 
ing condition causing it — nephritis, myocarditis, or anemia, etc. — 
should be looked after in order to prevent its recurrence. 



Pneumonia 

Here we have to treat not only a local inflammation with an 
exudate of fibrin and leukocytes into the air vesicles, but also a 
constitutional intoxication with the usual effect of such intoxica- 
tion on the nervous system. The work of the therapeutist must be 
directed, therefore, not only toward combating the spread of the 
local disorder, but also toward sustaining the bodily functions and 
neutralizing the effects of the bacterial toxins until the disease has 
run its course. Of course this would include, in an ideal scheme, 
the neutralizing of these toxins by the use of sera from animals 
immunized to the bacteria causing pneumonia, but as yet we have 
not developed any sera that are sufficient for the purpose. Hence 
our work is practically confined to the stimulation of the bodily 
functions and the protection of the tissues against any accident 
due to changes in 
temperature, unwise 
activity, indigestible 
food, etc. 

The local condi- 
tion is probably best 
treated by producing 
about the patient an 
even temperature, 
warm enough to pre- 
vent any drain upon 
the patient's vitality 
and yet at the same 
time permitting the patient to breathe air that is pure and cold 
enough to be a stimulant to the respiratory surfaces. Where the 
room temperature cannot be perfectly controlled, the protection to 
the chest is obtained by applying a jacket made up of uniform 
layers of cotton (the so-called pneumonia jacket) and sewed on, 
from the neck to the waist. This produces also a helpful hyperemia 
about the throat of the patient. Some practitioners try to obtain 




Fig. 22. — Applying a Clay Poultice. 



146 DISEASES OF THE RESPIRATORY TRACT 




Fig. 



23. — Covering the Clay Poultice with 
Cotton Jacket. 



the 



the same effect by applying a thick clay poultice, such as we men- 
tioned for tonsillitis. This, however, has the disadvantage of 
requiring changing after twelve or twenty-four hours, while the 
cotton jacket may remain on for several days at a time, if neces- 
sary, without injury 
to the patient. The 
matter of changing a 
poultice is of greater 
importance than 
would appear at 
first sight, because 
patients suffering 
from such severe dis- 
ease as pneumonia 
show such extreme 
prostration that 
every effort must be 
made to keep them 
from using more 
strength than is ab- 
solutely necessary. Hence, also, frequent examination of the chest 
should be avoided, although we must keep close watch for changes 
in the patient's condition. 

The air of the room should be kept at about 68° F. by admit- 
ting freely the air from out of doors. To prevent draughts, screens 
should be placed between the bed and windows, and the patient's 
body protected by a light flannel shirt or by the jacket mentioned 
above. The air of the room should be kept moist by the use of 
steam, as mentioned for bronchitis, especially if the climate be a 
dry one. The nurse should not regulate the temperature by her 
feeling, but by the consistent use of a thermometer. 

The constitutional treatment consists first of all in watching the 
heart and arterial system and stimulating them according to the 
changing conditions. When, because of the obstruction in the 
course of the pulmonary circulation, the right heart seems to be 
overburdened, digitalis is used to drive the blood in greater quan- 
tities to the extremities, and by means of the prolonged systole 
refresh the heart muscle. It is best used on the slightest suspicion 
of the heart's weakening, which should be aroused by a fall in 



THE LUNGS 147 

the blood pressure, in order to allow from twelve to twenty hours 
for its taking effect. Of digitalis, digitoxin is probably the efficient 
principle, but this cannot be used hypodermically because so in- 
soluble. Therefore for subcutaneous medication (and we use sub- 
cutaneous administration when the stomach is at all upset) we 
have recourse to digitalinum germanicum, which affords a more 
rapid action than if the entire drug were used by mouth. In using 
digitalis, one should always remember its slow action and its lia- 
bility to cumulative effects ; hence it is best to give the drug early 
and in heavy doses. Furthermore, we should use it only for a short 
time and then stop entirely. For instance, if one is using tincture 
of digitalis, one may give thirty-drop doses every four to six hours 
for three days and then stop. If one is using Merck's digitalinum 
germanicum, it may be used even as high as one to two grains 
(ordinarily one fourth of a grain) at a dose every four to six hours 
until the emergency has passed. Unfortunately this preparation 
contains a large quantity of digitonin, which is depressant in its 
action. Digitalis steadies and slows the heart, compelling the 
blood to flow through the lungs more rapidly, thus having a tend- 
ency to give better blood to the lungs, as well as to freshen up the 
heart. The use of digitalis is therefore justified even when there is 
no actual collapse of the heart. 

When the skin becomes clammy and pale, atropin is used in the 
dosage of ■£$ of a grain (best subcutaneously) to dilate the capil- 
laries and equalize the blood pressure. This also tends to reduce 
the burden on the right heart and dry up the secretions clogging 
the bronchi. 

Some attention should also be directed toward keeping the fever 
within reasonable bounds. What these bounds are depends, of 
course, on the individual patient, and if the patient is bearing the 
temperature easily, it is ordinarily unwise to reduce the tempera- 
ture by depressants. The reduction of temperature, when neces- 
sary, may be accomplished either by cold rubs or antipyretic drugs. 
Thus acetphenetidin in five-grain doses is used by some to reduce 
the temperature, but since its effect on the blood is bad, it should 
be avoided whenever possible. Other physicians use drop doses of 
the tincture of aconite, especially at the beginning of the fever, 
every hour as a routine measure for this purpose; but frequent 
sponging with cool water is a safer procedure than the giving of 



148 DISEASES OF THE RESPIRATORY TRACT 

internal antipyretics, or the ice bag may be applied to the chest 
if a nurse is not constantly available. 

The excretory organs must be kept active enough to carry 
quickly from the body the products of the excited metabolism. For 
this purpose the saline cathartics and calomel are preferred to the 
vegetable cathartics. 

Dr. Galbraith, of New Mexico, has reenunciated the belief, at 
one time quite prevalent, that pneumonia may be aborted, or at 
least greatly lightened, in its course by the use of enormous doses 
of quinin in the first three days of the disease. For instance, in 
the first twenty-four hours eighty grains of the quinin bisulphate 
may be given ; in the next twenty-four hours fifty grains ; and in 
the next, from fifteen to twenty-five grains. If the disease at that 
time still persist, then he would stop the quinin and proceed along 
the regular line of symptomatic treatment. In weighing the value 
of this line of treatment, one should remember that quinin is not 
a drug that is neutral or negative in all other lines than the one 
for which it is given, and that its toxic action on the heart and 
central nervous system might be sufficient to make it dangerous in 
itself. Therefore one should be cautious about giving this type 
of treatment in any case except with the most robust individuals. 

Strychnin acts upon the spinal cord, and if the respiration 
seems to be getting irregular and shallow, strychnin is the indi- 
cated remedy. In giving this drug, it should be remembered that 
its action is rapid and evanescent, although the total excretion lasts 
from two to eight days. It is better, therefore, to give it in small 
doses frequently repeated than in larger doses at longer intervals; 
e - g-> eV °f a grain of the sulphate or the nitrate every two hours 
rather than ^ of a grain every four hours. 

To raise the blood pressure and restore the vasomotor tone caf- 
fein and sodium benzoate hypodermically in one- to two-grain doses 
may be found necessary. I prefer, however, a neutral oil solution 
of camphor in 2-c.c. dose (6 c.c. pro die), hypodermically. This 
needs some four hours for effect, and hence cannot compete with 
caffein in rapidity of action. Frequently the two drugs may be 
given together, the camphor to supplement the caffein. Strychnin 
has the advantage over caffein and camphor in its stimulation of 
the appetite and digestion, but its evanescence and reaction make 
it less reliable. 



THE LUNGS 



149 



If the simple pneumonia pack does not seem sufficient to bring 
about the local absorption desired after the crisis, hyperemia may 
be increased by the use of the alternation of hot and cold cloths 
or by the application of hot fomentations to the skin of the chest 
and back. These applications should not be made so as to fatigue 
the patient, and it is better to leave them out entirely than to run 
any risk of exhausting the reserve strength, hence they should be 
used only in those 
cases of slow resolu- 
tion where the pa- 
tient seems otherwise 
convalescent, but 
where local stimula- 
tion is needed. To 
apply the hot and 
cold fomentations, the 
following procedure 
is suggested: A cloth 
wrung out in hot 
water is laid over the 
consolidated area and 
leit lor three to live jp IG 24. — Fomentation to the Back of the Chest. 
minutes. This is fol- 
lowed by a cold cloth for the same length of time, and so on from 
thirty to forty minutes. Have the boiling water in a large pail. 
Fold the cloth about four times. Taking an end of it in each hand, 
immerse as much of the cloth as possible in the boiling water and 
when it is thoroughly saturated, twist the ends of the cloth in op- 
posite directions, thus wringing the cloth without placing the hands 
in the scalding water. Hastily shake out, smooth, fold to the 
required size, and place within a dry cloth. The dry cloth should 
have been previously folded in thirds, so that either one or two 
thicknesses may be interposed between the hot wet cloth and the 
patient. To relieve pain renew the application every minute or 
two. When otherwise indicated, renew the fomentation about 
every three minutes, having a fresh fomentation ready to apply be- 
fore removing the one in place. 

The irritation of the bronchial mucous membrane (shown by a 
persistent and unproductive cough) is usually relieved by letting 




150 DISEASES OF THE RESPIRATORY TRACT 

the patient have steam to inhale. If the sputum is tenacious and 
the mucosa needs stimulating, turpentine should be put in the water 
in sufficient quantity to form a film ; but if the mucosa need more of 
a sedative effect, eucalyptol is better. Sometimes such a cough — if 
it be clearly not reflex, as from pleural effusion — is quickly relieved 
by a Priessnitz bandage or cold compresses over the trachea. In 
this connection I would reiterate the necessity of having the air 
of the room fresh and pure, and of protecting the body of the pa- 
tient from being chilled by this fresh air by means of warmer cover- 
ings and by screens between the bed and windows, because I believe 
that the temperature of the respired air has a very decided influence 
on the disease. Hence for steam inhalations one should arrange the 
apparatus so as not to vitiate the air of the room (e. g., we may gen- 
erate the steam outside the room and bring it to the bed in a tube). 

The condition of the intestines is of immense importance in this 
disease, therefore from the very beginning one should use thor- 
ough catharsis. Some men prefer for the initial drug calomel 
in two- to five-grain doses, others give heavy doses of mag- 
nesium sulphate or some similar saline cathartic. Whatever is 
chosen for the initial cathartic, it must be followed up by daily 
catharsis to prevent fermentation and intestinal toxemia, which 
might result from stagnation and add other dangers to the disease. 
For this purpose, one to two grains of calomel daily, administered 
in one-fourth-grain doses (best as calomel and wintergreen) will 
be found quite efficient. 

The diet should be stronger than that of typhoid fever or other 
enteritis, but should be liquid and easily digested. We give, there- 
fore, every three hours beef juice (not beef extract), grape juice, 
egg lemonade, eggnogs, gruels, etc., according .to the patient's di- 
gestion. If the digestion be bad, then peptonized foods should be 
used. The amount of food usually given at a feeding varies from 
four to eight ounces. Water may, of course, be freely given, and 
acidulated water will prove especially refreshing. For this the 
following prescription has been often used : 

IJ Acidi phosphorici 20.0 grams. 

Syrupi simplicis 20.0 c.c. 

Aquas 180.0 " 

Sig. One teaspoonful in water, as needed. 



THE LUNGS 



151 



In very robust subjects, the pulse is frequently so bounding and 
the blood pressure so high that relief by direct interference, such as 
a venesection or bleeding, is indicated. This should be carried out 
under aseptic conditions, as indicated in the following paragraphs. 

Phlebotomy. — Bloodletting has been in use since the earliest de- 
velopment of medicine. Hippocrates, Galen, and Celsus seem to 
have practiced it. It is mentioned in the Bible and Talmud. 
Among the primitive Arabs the term " son of a bloodletter " was 
one of reproach, and the bloodletters seem to have been suspected 
of being vain, gluttons, and unchaste. Rhazes (about a.d. 900) 
praised the procedure. Sydenham and Boerhaave laid great stress 
on bloodletting. This probably led to an extreme, and it was re- 
sorted to needlessly. Thus we find the following couplet under the 
name of Joh. de Mediolano: 

Exhilarat tristes, viatas placat, amantes 
Ne sint amantes, phlebotomia facit. 

The reaction came from the Vienna school, which adopted the ' ' ex- 
pectant " treatment for most diseases. Thus Dietl, a pupil of 
Swoda's, objected to its use in pneumonia in 1849. Lately, how- 
ever, bloodletting is coming into fashion again. 

Instruments. — One needs only^a small lancet (the old-fashioned 
lancet was sharpened on both edges, and provided with a tortoise- 
shell or horn handle, which enabled one to close it and carry it 
in the pocket) and a sterile gauze bandage two inches wide. Even 
this latter can be dispensed with and a handkerchief with collodion 
used instead. 




Fig. 25. — Median Vein. 



Place. — The vena mediana in the bend of the elbow is best 
adapted to the procedure. The places are well shown in the accom- 
panying cut. 



152 DISEASES OF THE RESPIRATORY TRACT 

Method. — The patient lies on the left edge of the bed. The 
doctor sits by the bedside so that the patient's left arm is between 
his own left arm and body. A bandage or compress is drawn twice 
about the upper arm and knotted on the outside. The doctor fixes 
the patient's arm with his left hand somewhat distally from the 
point selected for the opening. He grasps his lancet so that his 
finger tips are just a few millimeters from the point and sticks it 
into the vein, either parallel or somewhat obliquely to its course. 

The skin of the elbow should, of course, be cleansed beforehand 
for the operation by scrubbing with hot water and soap, followed 
by alcohol. It should be dry before the cut is made. 

As soon as sufficient blood is received in the sterile vessel (it is 
best to have a glass graduate in order to know at each moment how 
much has been removed) the bandage is removed from the upper 
arm and a small compress of sterile gauze is applied to the wound. 
This should be fastened into place with adhesive strips, and should 
remain in place for twenty-four hours, during which time the 
arm should be carried in a sling and kept quiet. After this, the 
compress may be removed and the wound sealed with collodion. 

The amount of blood to be taken is ordinarily only 100 to 150 c.c. 
(3 to 4 oz.). In very robust and plethoric individuals the amount 
may be increased to 500 c.c. The rule is to let 1 c.c. of blood for 
each pound of body weight. As a matter of historical interest, we 
quote the following table of amounts from the work of Marshall 
Hall, published in 1830, from the London Practitioner for March, 
1909: 

I. Augmented Tolerance. — Represented by the mean quantity of 
blood which flows before incipient syncope: 



A. Congestion of the hrain: 

(1) Tendency to apoplexy, 1 

(2) Apoplexy from congestion, j 

B. Inflammation of the serous membranes: 

(1) Arachnitis, 

(2) Pleuritis, 

(3) Peritonitis, 

(4) Inflammation of the synovial mem- 

brane and of the fibrous textures 
of the joints, 



40-50 oz. 



.30-40 oz. 



THE LUNGS 153 



C. Inflammation of the parenchyma of organs: 

(1) Of the substance of the brain, " 

(2) Pneumonia, 

(3) Hepatitis, 

(4) Inflammation of the mamma, 



30 oz. 



D. Inflammation of the skin and mucous membranes: 

(1) Erysipelas, 1 

(2) Bronchitis, V 16 oz. 

(3) Dysenteria, J 

II. Healthy Tolerance. — This depends on the age, sex, strength, 
etc., and on the degree of thickness of the parietes of the heart and is 
about 15 oz. 

III. Diminished Tolerance. — 

(1) Fever and eruptive fevers 12-14 oz. 

(2) Delirium tremens and puerperal de- 

lirium j 10-12 oz. 

(3) Laceration and concussion of the 

brain, 

(4) Accidents, before the establishment V . . 7-10 oz. 

of inflammation, 

(5) Intestinal irritation, 

(6) Dyspepsia 8 oz. 

(7) Cholera 6 oz. 

Accidents. — If the blood does not flow, the patient should close 
and unclose his fist, or rotate his hand. The doctor can help by 
massaging the veins. If little tags of fat get into the wound, one 
simply removes them with a knife or scissors. If the patient faints, 
one simply interrupts the procedure — no evil consequences occur. 
Thrombosis does not occur when the operation is carried out at 
all correctly. Only gross carelessness permits the operator to punc- 
ture an artery. 

The effect on the blood is to stimulate the blood-building organs 
and in from two to five days the number of corpuscles has returned 
to the normal. If the loss of blood reaches one third the total 
amount in the body, then it may take about fourteen days to secure 
normal conditions again. 



154 DISEASES OP THE RESPIRATORY TRACT 

Indications. — (1) Septicemia and toxemia. This indication in- 
cludes even carbonmonoxid and carbonic-acid poisoning. It is 
indicated also in uremia and diabetic coma. In many of these 
cases the blood is removed and sterile normal salt solution imme- 
diately put into the vein. (Release the upper bandage before be- 
ginning the injection of any solution.) 

(2) Circulatory disturbances, especially in cases of venous hy- 
peremia, as in pneumonia, cardiac failure, and pulmonary edema. 
It is even useful in plethoric conditions of the sedentary and obese. 

(3) Bloodletting may stimulate the building of the blood ele- 
ments sufficiently to make it a desirable procedure in gout, chronic 
rheumatism, and chlorosis. 

Complications of Pneumonia. — The delirium of pneumonia is best 
treated by the camphor injections and the application of cold (ice 
cap or Leiter's coil) to the head. 

Gastric irritation, vomiting, or diarrhea usually indicates that 
a mistake in feeding has been made. The intestinal tract should 
be immediately cleansed with salines (or castor oil) and then feed- 
ing cautiously recommenced with milk or broth as a basis. 

Pleurisy 

The inflammation of the serous membranes lining the lungs 
leads either to a thickening and roughening of the intrapleural 
surfaces, or to the formation of bands of adhesions between the 
two surfaces, or to the exudation of fluid into the pleural sac. 
This fluid may be serous and sterile, or sero-fibrinous, or sero-puru- 
lent. From the therapeutic standpoint, the amount, as well as 
the character, of this fluid is important, because the amount de- 
termines whether it interferes with the movement of the heart 
or lungs. And on the character depends whether or not it will be 
absorbed. 

Pleurisy is usually secondary to pneumonia and gives more 
distress to the patient than does the pneumonia itself, thus 
demanding the specific attention of the physician. The pain 
in pleurisy is due to the rubbing of the two inflamed and rough- 
ened pleural surfaces upon each other in respiration; there- 
fore this pain may be decreased by restricting the respiratory ex- 
cursions of the pleura and ribs. This is done by bandaging the 



THE LUNGS 155 

lower ribs tightly with adhesive plaster, so that the patient can 
breathe only with the diaphragm and upper ribs. Then, too, some 
of the pain may be done away with by using heat locally in the 
form of hot-water bottles, hot irons, the thermophore, etc. Usu- 
ally, we try these mechanical procedures before any drugs are 
given. 

Morphin is the only drug that is efficient in banishing the pain ; 
and in cases of pleurisy accompanying pneumonia, it should be 
given with the hypodermic needle in the dose of J to J grain, ac- 
cording to the reaction and condition of the patient. Thus, if the 
patient be a child, the dose should be -fa to J of a grain ; if the pa- 
tient be an adult and habituated to morphin, the dose should be 
J to J grain. On the other hand, we find patients whose respira- 
tion and heart action are readily depressed by morphin even in 
|-grain doses. If the patient be a stranger to the physician, it is 
wise for him to give first J of a grain and stay and watch the effect, 
repeating the dose in one half hour if necessary. 

For the absorption of the exudate, potassium iodid is a useful 
drug. This acts simply by hastening the process of catabolism, 
thus producing a house cleaning in the body. This house cleaning 
carries with it the cleaning up of the pleural sacs also, but in no 
wise is the action a specific one. Hence the use of potassium iodid 
is very frequently without any perceptible result at all ; and then, 
other measures (chiefly hydrotherapeutic) looking to the produc- 
tion of a hyperemia in the chest, must be resorted to. 

Another drug for similar purposes is guaiacol. This is given 
in a dose of two to fifteen drops rubbed well into the chest or ab- 
domen. Its action is to produce, when absorbed, a similar catabo- 
lism to that of the iodids, but it has also an antipyretic action on 
the nerve centers and an antiseptic action on the tissues through 
which the drug is absorbed on its way to the circulation. The anal- 
gesic effect of guaiacol when applied locally in this way should be 
kept in mind, because it will frequently enable us to avoid the use 
of morphin or other habit-forming or depressant drugs. 

Fibrolysin may be used in cases of old adhesions and roughened 
pleurge to remove the inflammatory tissue and restore the two rub- 
bing surfaces to their integrity. 

Fibrolysin hypodermically may be of assistance in bringing 
about the absorption of an exudate. It should be given in doses of 



156 DISEASES OF THE RESPIRATORY TRACT 

1.13 c.c. daily for two days, then in double that dose on alter- 
nate days. 

In exudative pleurisy drugs are often not sufficient to rid the 
body of the exudate, hence operative procedures are demanded. 
The usual procedure is called thoracocentesis, and is described in 
the following paragraphs. 

Thoracocentesis. — Even Hippocrates practiced opening the 
pleural cavity. It seems, therefore, the more wonder that for hun- 
dreds of years the procedure was not even mentioned in medical 
writings. It is interesting to note that Hippocrates advocated 
washing the body with much water before undertaking the opera- 
tion. This was evidently a striving after asepsis. The opening was 
usually made in those days with the knife, but preferably with the 
actual cautery. 

Bowditch deserves the credit of introducing pleural aspiration 
into modern practice (1872). In the first half of the nineteenth 
century the results of the operation had been so unfavorable that 
few dared to resort to it. Now, thanks to our aseptic methods and 
the use of the aspirator, the procedure is both easy and without 
danger. 

Indications. — The indications for the operation are three : 

1. When there is danger of the patient's dying because of fluid 
in the chest cavity. (This of course demands a careful analysis 
of the patient's symptoms in order to exclude the other possible 
causes of the dyspnea and disturbed circulation.) Such danger 
may lie either in the quantity of the fluid or in its septic or toxic 
nature. 

2. Every great exudate should be emptied even if there is no 
present danger to life. Trousseau sets the limit at two liters, and 
stated that if such an exudate remained for some time without re- 
sponding to energetic medication, it should be removed. In illus- 
tration of the danger of neglecting such large exudates, Frantzel 
(quoted by Gumprecht) relates the following incident: 

When I was clinical assistant at the Charite I was put in charge of 
a case of pleuritic effusion. I made a careful examination and decided 
that thoracocentesis was necessary, but because it was late in the even- 
ing postponed the operation until next morning. During the night the 
patient suddenly called to the nurse for help, but was dead before the 
latter reached the bedside. 



THE LUNGS 



157 



That is, these great exudates may cause death without any warning 
sign of dyspnea and special circulatory disturbance beforehand. 

3. Delayed absorption is the last indication. The usual time 
during which we should wait is placed at four weeks. 

Usually thoracocentesis is carried out for Indication 3 oftener 
than for the other two together ; e. g., 75 per cent of all such op- 
erations are done for this reason. Indication 2 has been utilized in 
4.5 per cent of the cases in Basle and 30 per cent in Zurich, thus 
becoming the least used of the three. 







Pressure at 


Respiratory 


Amount 


Author. 


Beginning. 


End of 


Difference in 


Removed 




Aspiration. 


mm. of Mercury. 


in c.c. 




+ 8 


-10 










± 


- 6 










+ 12 


- 8 


+ 30 








+ 6 


-20 


10-20 






Leyden -1 


± 


-12 


-32 








+ 28 


-12 


8-16 








+ 12 


-12 


8-16 








- 1 


- 4 










± 


-28 


-42 








+ 8 


-1 


+ 30 


3,200 




+ 8-12 


-2-3 


+ 36 


1,100 


Quincke -< 


+ 16-20 
+ 5-6 


+ 2 
-1 




2,000 
2,000 




+ 10-12 


-2-0 




2,000 


\ 


+ 25 


-8-9 




1,500 


i 


+ 4 




-74 


1,000 


Schreiber < 


+ 20 


-24 


-30 


500 




± 




-80 90 


400 




- 6 


-6 


±12 


250 




- 7 


- 7 




1,600 




+ o 


-12 




1,500 




+ 11 


-24 




2,000 




-10 


-34 




3,200 




+ o 


-30 




1,500 


Keberlet J 


+ 4 


-10 




1,000 




- 8 


-24 




2,000 




- 6 


-20 




2,000 




-16 


-26 




2,000 




± 


-16 




4,250 




-20 


-20 




1,700 



158 DISEASES OF THE RESPIRATORY TRACT 

It is generally found better not to attempt to remove all of 
the fluid, but rather to limit ourselves to 1,500 c.c. (three pints), 
or the amount with the removal of which the patient suffers no 
inconvenience. The table on page 157 shows the pressure at 
the beginning and end (measured in millimeters of mercury) 
within the thoracic cavity. This demonstrates how great the 
difference in pressure may be and what dangers it may pre- 
sent. 

Test Puncture. — Before proceeding to the removal of the 
pleural fluid it is usually worth while to make a test puncture with 
a syringe. For this purpose, the all-glass syringe of Hanhart & 
Ziegler (of Zurich) is best. At any rate, the syringe used must be 
air-tight and thoroughly sterilized. The needle, of course, should 
not be boiled, but rather sterilized in two-per-cent formaldehyd 
solution and then dried out in alcohol. The skin should also, of 
course, be thoroughly sterilized with soap and water, followed 
by bichlorid (1:1,000) and alcohol. When everything is ready, 
the operator holds the syringe in his first three fingers with the 
piston fast in his palm and plunges it quickly into the selected 
intercostal space. If fluid is present, some will appear in pulling 
on the piston. If blood appears, it usually means that the lung 
has been punctured; if air, then either the needle has penetrated 
the lung or there is a pneumothorax present. By moving the 




Fig. 26. — Conditions in which the Aspirating Needle Fails to withdraw 

Fluid. 



point of the needle about, one can usually reach the fluid when 
the first stroke does not touch it, and can at the same time deter- 
mine whether the point of the needle is in the pleural cavity or in 



THE LUNGS 



159 



the lung. When pus appears in the syringe it indicates that a re- 
section of the ribs rather than an aspiration is demanded. Three 
reasons for not reaching the fluid are shown in Fig. 26. 

The Aspirator. — In the old days a simple trocar was used and 
a fluid exudate allowed to flow out under its own pressure. Now, 
however, a bottle with a suction pump is attached to the trocar or 
needle and the fluid withdrawn by negative pressure. 

Two sorts of needles are in use. The one sort is simply a 
large hypodermic needle with extra holes on the side. The 
other is a trocar with a sheath. The former may possibly 
irritate the lung tissue 
as it is moved about 
while in the thorax. The 
latter, since it has no 
point to the sheath, is 
less liable to injure the 
tissues within the chest 
wall. On the other hand, 
it is difficult to secure a 
trocar to which the sheath 
fits so snugly that there 
is no escape of air. A 
moment 's reflection will 
show how important this 
latter point is, especially 
in those cases in which 
the needle or trocar must 
be inserted with the suc- 
tion in force. Hence the 
author prefers the Po- 
tain aspirator with the needle 
lustration. 

The graduated bottle in the Potain outfit is quite important be- 
cause it furnishes a clean receptacle for preserving the fluid, and 
at the same time is a measure of the quantity withdrawn. There 
are, however, on the market aspirators without the bottles, which 
are more easily carried about. For the reason just stated, however, 
we prefer the bottle type (Potain) to the other shown below 
(Truax). 

12 




Fig. 27. — The Potain Type of Aspirator. 



as shown in the accompanying il- 



160 DISEASES OF THE RESPIRATORY TRACT 

We prefer also the metal pump to either the rubber bulb x or 
the screw aspirator, because it is more durable and is easily con- 
trolled. 

The Place. — It is said that, other things being equal, the best 
place for inserting the needle is in the fifth or sixth intercostal 




Fig. 28. — The Teuax Aspirator. 

space in the anterior axillary line. But, in general, the point must 
be one where the percussion note indicates the presence of fluid 
and must be as far as possible from the heart and diaphragm. Fur- 
thermore, the point on the chest wall should be where it is as thin 
as can be selected, and the opening made should be favorable for 
the flow of the fluid. On these points, the following figures will 
be useful : 



1 Gumprecht relates the following incident which shows a possibility from 
the use of a rubber bulb. The patient was a robust man suffering from serous 
pleurisy. The aspiration with the needle produced no results; so the attendants 
began to squeeze the bulb to suck out the fluid. Suddenly the patient began to 
complain of a severe pain in his chest and became cyanotic. The affected side 
of the chest had swelled out very noticeably and a pneumothorax was quickly 
diagnosed. The trouble was found to be in the bulb, which had been turned 
about and was driving the air into the lungs instead of pumping it out. This 
was corrected and a part of the air aspirated. The pneumothorax disappeared 
in a few weeks with no evil results except that the convalescence was some- 
what delayed. 



THE LUNGS 161 

The course of the lower edge of the lung reaches as follows: 

At the midsternal line, lower edge of the sixth rib. 
At the mammillary line, upper edge of the seventh rib. 
At the axillary line, lower edge of the seventh rib. 
At the scapular line, lower edge of the eleventh rib. 

The height of the complementary space is: 

In the parasternal line, 2 cm. 
In the mammillary line, 4 cm. 
In the axillary line, 9 cm. 
In the paravertebral line, 3 cm. 

Hence one has considerable latitude even in the normal chest 
for inserting the needle, especially in the axillary space. 
The points recommended are: 

Bowditch, ninth intercostal space (seventh to tenth), scapu- 
lar line. 

Dieulafoy, eighth intercostal space, scapular line. 

Naunyn, eighth intercostal space, just behind the axillary 
line. 

Trousseau, seventh intercostal space, on the right sixth axil- 
lary line. 

Schuh, fifth to seventh intercostal space. 

Wintrich, fifth intercostal space, behind the attachment of 
the serratus anticus. 

Gerhadt, sixth intercostal space, between nipple and axil- 
lary line. 

Frantzel, fifth intercostal space (on right side, fourth), 
from mammillary line to the axilla. 

The flow should be slow. The old rule required twenty minutes 
for a liter. Whether the flow be as slow as this or not, at any rate 
the slow aspiration runs less danger of bringing on an attack of 
coughing or other unpleasant results of lung irritation. 

The aspiration may be repeated daily if need be. Exudates, as 
a rule, return less frequently than transudates. In general, we 
may say that the original indications mentioned above are in force 
also for repeating the aspiration. 



162 DISEASES OF THE RESPIRATORY TRACT 



Double-sided hydrothorax should not have both sides emptied 
at one sitting. The side containing the greater quantity is opened 
first, and the next day the other. 

Hemorrhagic fluid demands great caution. Usually some severe 
disease lies back of it which of itself would be fatal, so that the 

aspiration can help but little. The 
rule is that one should not exceed 
one half liter in the amount with- 
drawn. 

Accidents. — Cough is the most 
common, hence it is well to inject 
a dose of morphin hypodermically 
before the aspiration in any case 
where there is the least danger of 
such trouble. 

The pain caused by the rubbing 
of the inflamed pleura can also be 
avoided by using the morphin be- 
forehand. These pains may last for 
a day and require additional doses 
of morphin. 

Syncope is quite common. In 
such cases the patient should be 
laid flat and given brandy or 
strychnin and the aspiration re- 
sumed with the patient in the more 
horizontal position. This danger 
of syncope should be thought of 
at the beginning and the patient 
placed in as easy and as nearly 
horizontal a position as possible. 
Sudden deaths have occurred during the aspiration. They have 
been found to be due to cardiac insufficiency, as a rule. Hence a 
careful estimate of the cardiac strength should be made before un- 
dertaking an aspiration. The accident is rare. 

The clogging of the canula or needle with fibrin is also a 
rare occurrence, and can be overcome ordinarily by moving the 
needle. 

The spasms that have occurred following aspiration and costal 




Fig. 29. — Points Recommended for 
the Insertion of the Aspirat- 
ing Needle. 



THE LUNGS 



163 



resection are sometimes due to intoxication from the antiseptic fluid 
used to irrigate the cavity with ; e. g., in case of empyema. In 
other cases they seem to be simple reflexes from the pleural irri- 
tation, and are oftenest encountered in hysterics. There is a record 
of sixteen deaths in thirty-eight cases of spasm. 

Pleuresies Bloquees. — Sometimes every physical sign indicates 
the presence of fluid in the chest, and yet none can be withdrawn 
through the aspirating needle until one inserts .a second needle 
unconnected with an aspirator near the first, when an abundance 
of fluid escapes. Such cases are examples of the pleuresie bloqae 
of Mosny and Stern (La Presse Medicate, December 11, 1909). 
The difficulty in aspiration is due to the thickening and stiffening 
of the thoracic walls — in particular the thickening of the dia- 
phragmatic pleura — so that when the lung tissue is also thickened 
and hardened, as is liable to occur in tuberculous and fibrous pneu- 
monias, the walls do not yield to the negative pressure (vacuum) 
caused by the aspiration. The fluid therefore cannot escape until 
it is replaced by air or other substance. 

The apparatus for replacing the fluid with sterilized air is like 
the accompanying cut. Here T is of glass in the shape shown, one 




Fig. 30. — The Mosnt-Stern Apparatus for Aspirating a "Blocked" Pleurisy. 



end being connected with the needle, B, one with the aspirator, A, 
and the third with the air supply. The latter consists of two flasks, 
E and F, connected with rubber tubing. E is empty, F filled with 
warm sterile water. D is a bulb (of glass) filled with sterilized 
cotton. Note that E is graduated. To begin we take out the cork 



164 DISEASES OF THE RESPIRATORY TRACT 

/ and raise the flask F above E until some water runs into E. We 
then replace /, and place F on a level with E. The needle, B, is 
introduced into the pleural sac and a is opened and aspiration 
is begun. If the exudate is not completely blocked, some fluid will 
escape through A. As soon as the fluid ceases to flow, a is closed, 
and c opened. Then / is removed again and the siphon action will 
cause some water to flow from F to E and drive the air thence 
through D and C into the pleural sac. The volume of air can be 
measured by noting the quantity of water in E. We then close c 
again, open a and begin aspirating anew. As soon as the flow 
ceases we let in air again, and so on, until we have removed 
all the fluid we dare. In general, we remove all the fluid present, 
if thoracic pain and dyspnea do not intervene. 

Mosny and Stern advise against emptying out the cavities in 
acute cases where the exudate is rich in polymorphonuclears and 
endothelial cells (" splenopneumonia "), but urge the evacuation 
of the exudate in chronic cases where lymphocytes predominate. 



PHTHISIS 

General Treatment 

Tuberculosis of the lungs is not a self -limited disease, therefore 
it is necessary to make a definite attack on the disease if one is to 
succeed in its treatment. For example, pneumonia produces re- 
active antibodies which immunize the body fluids to the disease, 
and the physician has only to protect the organism until the dis- 
ease shall have run its course. But in phthisis one must make 
an aggressive effort to check the disease or the patient will 
perish. The most successful efforts made toward checking the 
progress of tuberculosis have been indirect ones rather than direct ; 
that is, those measures made at increasing the resistant and germi- 
cidal power of the body tissues and fluids have been more success- 
ful than antiseptics and germicides applied to the infected tissues 
themselves. Naturally, however, one is not willing to neglect any 
means from which he can hope for good results, therefore he would 
give antiseptics, but at the same time put his chief dependence 
upon building up the bodily defenses. 

Probably the weakest point in the body in consumption is the 



PHTHISIS 165 

digestive tract. Therefore the greatest amount of effort must be 
made to secure increased absorption and assimilation of food, es- 
pecially fat. In fact, some physicians go to the extent of believing 
that in furnishing fats to the body one furnishes the real remedy 
for the disease, and that the essential pathology of phthisis lies in 
its fat-destroying power. Be that as it may, fats are hard to digest 
at any time, and naturally worse in times of digestive weakness; 
consequently, if one attempts to increase the amount taken by tu- 
berculous patients, it necessitates a complete regulation of the 
dietary and generally also a stimulation of the digestive organs. 
Hence our first duty to our consumptive patient is to supervise and 
regulate his dietary and methods of eating. 

The principles noted in caring for diseases of the stomach should 
be remembered here ; that is, a few staple, carefully selected foods 
should be used instead of permitting a great mass of odds and ends 
of food to be given the patient. Thus milk and buttermilk can be 
given in rather great quantities if too many other kinds of food 
are not mixed in with them. Similarly steak and toast make a 
diet which one could use for a week or two with very good results ; 
and then again eggs and vegetables form a good combination to 
stimulate the digestive function. Food should be given every three 
hours, and the quantity should be limited only by the digestion of 
the patient. At any rate, it must be greater than a healthy person 
would take under like circumstances. Thus a diet of steak and 
toast at the regular three mealtimes, and four to eight ounces of 
lactone buttermilk, yogurt, or eggnog, at say ten and four o'clock 
would be advisable for perhaps a fortnight. Then an egg diet of 
say three eggs at each of the principal meals and two eggs each at 
ten, four, and eight o'clock would do for another fortnight. These 
eggs would, of necessity, be carefully and differently cooked. With 
the eggs one could allow one vegetable, bread (better, toast or 
triscuit) and butter, and milk to drink. Another illustrative diet- 
ary for a patient with a slight hectic fever, living in a tent, is the 
following : 

7.00 a.m. — Hot chocolate (made with full milk). 
7.30 a.m.— Cold bath and rub. 

8.30 a.m. — Breakfast: steak, toast (buttered), coffee with milk. 
10.30 a.m. — Lactone buttermilk, four to eight ounces. 



166 DISEASES OF THE RESPIRATORY TRACT 

12.30p.m. — Dinner: steak, toast (buttered), cauliflower cooked 
in milk (or some similar vegetable), rice, custard. 

3.30 p.m. — Lactone buttermilk, wafers. 

6.30 p.m. — Supper : steak, toast with plenty of butter, tomato 
and lettuce salad with, mayonnaise dressing, 
cooked fruit. 

8.30 p.m. — Eggnog (two eggs). 

This would grow monotonous in about two weeks and should then 
be changed. 

"We find that if patients live in the open air and live regular 
lives, they have fewer digestive disturbances than otherwise. It 
may, however, be necessary at the beginning of the treatment to 
use gastric lavage and put the stomach into good working order. 
At any rate, the ingestion of good food is a sine qua non, and the 
whole life of the patient must be arranged to this end. Further- 
more, we find that it is much easier to prevent digestive disorders 
than it is to cure them ; that unless we can secure the full control 
of the patient's life it is useless to undertake the case. 

It goes without saying that patients suffering from active 
phthisis should not be allowed to smoke. 

The amount of fat given the patient should be as great as pos- 
sible. I find it very good practice to give an ounce of olive oil 
three times a day after eating. By securing high grades and giv- 
ing it (if necessary) with coffee, one can make almost every pa- 
tient take the oil. Or one may prescribe considerable salad with 
relatively large amounts of mayonnaise dressing. If given after 
the meal it rarely interferes with the gastric secretion of hydro- 
chloric acid. 

As in pneumonia, so here, the breathing of pure, cold air is ex- 
ceedingly beneficial. In order to obtain such air, the patient should 
live out of doors the entire twenty-four hours. A tent is far better 
than even an open shanty or log cabin. If it is impossible to have 
a tent out of doors, one can accomplish a similar result (as far as 
the respired air is concerned) by having a tent bed next the win- 
dow. This enables the patient's chest and face to be practically 
in the open air while the remainder of the body is in the room, and 
it does not chill the interior of the house as it would to have all 
the doors and windows open. Nor does it create draughts which 



PHTHISIS 167 

would have an unfavorable effect on a weak patient. Where suit- 
able ground space is not available tents may be placed on porches 
and roofs, and this in warm weather is preferable to the window 
tents. The tent should be at least ten by twelve feet, with a board 
floor raised twelve to eighteen inches above the ground. The sides 
may be of boards up to thirty or thirty-six inches, but above that 
they should be of canvas. Small stoves may be put in the tents 
for warming the air during baths and dressing hours. At other 
times, the air should be cold and the patient should depend on the 
bedclothing for warmth. The tents should have the sides raised 
every day except in inclement weather, and should be kept scrupu- 
lously clean. 

The condition of the skin needs careful attention in tubercu- 
losis, and the stimulation of the skin by cold rubs every morning 
is very important. If the patient is strong enough to take a cold 
tub (water at 70° to 80° F.) , well and good. 1 If not, then he should 
be given a very brisk rub with cold water at the hands of a vigorous 
nurse. A rub with oil in the evening is also very beneficial, inas- 
much as the massage, coupled with the application of the oil, keeps 
it in good order and quiets the patient for the night's rest. Of 
course, where available, further invigorating hydrotherapeutic 
procedures may be prescribed for the stronger patients, but they 
should be selected and supervised carefully and individually. No 
mass or class prescriptions should be given. 

During the continuance of the fever the patient should be kept 
in bed practically all the time. When fever free, the patient should 
be given mild exercise in the open air. For this those forms 
should be chosen that lead the patient to breathe deeply and use 
his chest muscles. For instance, pitching quoits is better than 
walking. Horseback riding is good for those in whom it does not 
start up a fever. Driving is good for only the weakest. Working 
about the flowers and vegetables in the garden is better than loung- 
ing about the porch. Tennis and hand ball are good, of course, 
only when they do not excite the fever. No exercise should be 

1 Dr. R. T. Sloan states that it is dangerous to order cold baths for phthisical 
patients because of the danger of (1) irritating old pleuritic adhesions, (2) setting 
up hemoptysis, and (3) of requiring too great muscular exertion. These dan- 
gers should be weighed before we order such baths. In my own experience no 
damage has resulted from such cold baths as I have found it wise to order. 



168 DISEASES OP THE RESPIRATORY TRACT 

taken to the point of fatigue, hence at first it is better to specify 
particularly the kind and length of exercise each patient may have 
each day. 

Ortner gives the following rules, which may serve us as an 
illustration of a suitable set of exercises: 

(1) Arms: raising the extended arms over the head from one side, 
raising the arms over the head from in front, swinging the arms for- 
ward, up and backward, swinging the arms in a sagittal plane. (2) 
Legs: raising the leg forward, sideways, backward, spreading the legs, 
bending the knees. (3) Trunk: bending at the waist, raising oneself 
from a horizontal position, twisting the trunk, etc. (4) Lungs: slow 
breathing with the hands on the hips, holding the breath, forced in- 
spiration, deep breathing with arms stretched backward. The following 
is an example of a suitable combination of movements: 

Raising the arms from the sides 10 20 30 times 

Slow breathing, hands on hips 10 

Spreading the legs 6 

Rolling the shoulders 10 

Holding the breath (thirty seconds) 2 

Slight bending of knees 8 

Swinging the arms forward, over, and back . 12 

Forced inspiration 4 

Twisting the trunk 10 

Swinging the arms in a sagittal plane 6 

Expanding the chest 2 

Deep bending of knees 6 

The clothing of the patient should be light and airy, not heavy 
and cumbersome. All the clothing should be changed at night and 
warm pyjamas donned. Patients should never be allowed to put 
layer after layer of clothing over the chest or wear chest pads. On 
the contrary, the chest clothing should be such as to give the freest 
play to the thoracic musculature, and also ventilate the skin well. 
The mesh of the underwear is more important than the material. 
Thus the loosely woven cotton and linen are better than tightly 
woven woolens. Under the hygienic treatment here suggested, 
patients soon lose their fear of draughts and exposure to the bra- 
cing air. 



20 


30 


15 


20 


8 


10 


15 


20 


2 


2 


16 


24 


18 


24 


6 


8 


15 


20 


10 


16 


3 


4 


9 


12 



PHTHISIS 169 

Climatic Treatment 

The weight of evidence seems to be that while climate may play 
an important role in the treatment of consumption, it is not of it- 
self sufficient to cure the disease; hence to send a patient from a 
climate in which he may have good care and medical service to one 
in which he would receive little or none would be unwise. Fur- 
thermore, wherever possible, the patient should take the treatment 
in the climate in which he is going to live; that is, he must be 
immunized to the disease under the actual conditions that will gov- 
ern his own life. In view of these two facts, the treatment of 
consumption must for the great majority of our people be given 
in their home climate, and the discussion of the relative values of 
recommended resorts will be of practical application to only the 
wealthy and foot-loose. 

Of course, the purer the air the better for the patient; hence 
country is better than city, sea than land, mountain or desert than 
cultivated plain. 

The temperature has considerable influence, for the cool, bra- 
cing weather of Colorado is better than the enervating warmth of 
the Gulf towns. In fact, some observers believe that the coldness 
of the climate is essential in climatic cures. But probably of more 
importance than the average temperature is the range of tempera- 
ture, and whether the changes are sudden or gradual. This makes 
inland towns harder for weakened patients than coast towns, even 
though the best climate inland seems better than the best climate 
on the coast. 

Altitude stimulates all the metabolic processes of the body, 
hence altitude is a desirable quality in favor of a sanatorium in 
Colorado as against one in Missouri. Altitude is not indispensable, 
and in fact, unless one can continue to live at that height above the 
sea, can be thought of only as a temporary stimulation. 

With many patients change of climate may be helpful, not for 
the absolute value of the climate itself, but for the stimulation 
afforded by change of environment. Of course, in calculating this 
value, one must weigh against it the wear and tear of the extra 
exertion involved in the change. 

Our advice is then to seek first of all the conditions under 
which good treatment may be given, and if the patient's purse 



17Q DISEASES OF THE RESPIRATORY TRACT 

permit it, then select the climate that affords the purest air and 
greatest stimulation to the particular patient, because some pa- 
tients have respiratory passages that are better in a relatively 
moist climate, as that along the seacoast or on an island in the 
Pacific ; others must have the dry climate of Colorado or New Mex- 
ico. But these considerations are apart from the treatment of the 
tuberculosis, and are determined by the diathesis of the individual. 
The following catalogue of resorts is adapted from the excel- 
lent text-book of Ortner, edited by Potter. We can learn of sana- 
toria in the United States resorts by consulting the Directory of 
the American Medical Association: 



WINTER AND SUMMER RESORTS ABOVE 3,000 FEET 

European 

Davos-Platz, 5,350 feet, much dust and wind in summer, good sani- 
tary arrangements, sports in winter, large English colony (twenty-six 
hours from London). 

Arosa, 5,740 feet, hotels surrounded by hemlocks, six hours by car- 
riage from Chur. Both these resorts are in Canton Graubiinden, Swit- 
zerland. 

Ley sin, 4,757 feet, near Montreux, one hour by rail from Aigle (Can- 
ton Waadt). 

St. Moritz, 5,804 feet, in the Upper Engadin, beautifully situated, 
iron springs, a popular resort for English and Americans. Excellent 
winter sports. Colder and rather more wind than at Davos. Fewer 
seriously ill patients, more society. 

American, etc. (3,500 feet, and over) 
New Mexico: 

Santa Fe, 7,000 feet, seventy-five per cent of possible sunshine. 
Mean temperature 50.5° F. ; extremes, 7° and 89° F. Twelve to sixteen 
inches of rain. High winds in March and April. Fair hotels. 

Las Vegas, 6,418 feet. Good hotel at the springs. 

Albuquerque, 5,200 feet. Even less rain than in above places. 

Silver City, 5,800 feet. Sandy soil, pine forests, excellent place for 
out-of-door life. Average rainfall, 12.3 inches. Average number of 
cloudy days to the year, thirty-seven. Nine miles from Fort Bayard, 
which was chosen by the United States authorities as offering the great- 
est climatic advantages for the treatment of tuberculosis. 



PHTHISIS 171 

Eoswell, 3,570 feet. 
Eddy, 4,000 feet. Good hotel. 

Alamogordo, 4,400 feet. All three rather hot in summer. 
Las Cruces, 3,800 feet. Excellent winter climate with marked diur- 
nal variations in temperature, but the hotel is poor. 

Arizona : 

Arizona, with a similar climate to New Mexico, offers fewer resorts 
with sufficient comforts for delicate invalids. Very marked diurnal 
variations of temperature, pronounced dryness, two rainy seasons, dur- 
ing the summer and during the winter, intensely hot summers, mild, 
sunny, and favorable winters, and annoying alkali dust are the impor- 
tant general features. 

Prescott, 5,456 feet. Fair accommodations, excellent climate from 
September to February. 

Flagstaff, 6,800 feet. Near pine forests. 

Colorado : 

The plateau of Colorado, from 4,000 to 6,000 feet, possesses in 
general a mountain climate. The Rocky Mountains running from 
north to south still further diminish the degree of humidity by causing 
a precipitation of the moisture of the winds from the Pacific Ocean. 
Hence it offers a much lower degree of humidity, both relative and abso- 
lute, than would be accounted for by altitude alone. It is also pro- 
tected from the western winds, but not from the winds from the 
north and the east. The places in Colorado named below, as well as 
others with similar climatic conditions, are suited to patients with a 
considerable reserve of vitality. Those with feeble circulation and poor 
assimilation will nearly always do better at lower altitudes, in a warmer, 
moister climate. The same rule is generally applicable to the resorts 
in New Mexico and Arizona. 

Denver, 5,196 feet, population, 138,859 (1900), in an arid open plain, 
fifteen miles east of the foothills and thirty miles east of the main ridge 
of the Rocky Mountains. Large amount of sunshine, very little rain, 
a hot summer, cool winter, very dry, good deal of wind and dust. Ar- 
rested cases in patients of robust constitution who must live in a large 
town to make their living, will do well, although it is difficult to 
find work. 

Colorado Springs, 5,992 feet, ten miles east of Pike's Peak, which is 
14,000 feet, population, 21,085 (1900), is nearer the mountains, more 
winds, alkali dust. Patients require a good deal of vitality to do well. 
A rather social city for the better class. 



172 DISEASES OF THE RESPIRATORY TRACT 

Glenwood, 5,600 feet, 160 miles west of Denver; in a protected valley 
in the foothills, less wind and less dust than either of the above; ther- 
mal springs. 

Estes Park, 7,500 feet, for summer especially; excellent hotels. 

Mexico : 

City of Mexico, 7,400 feet, upon the central plateau of Mexico, is 
famous as possessing one of the favorable all-the-year-round climates. 
Accommodations are said to be inferior. 

South America: 

The Andes in South America furnish resorts in Peru, Ecuador, Co- 
lombia, 1,880 to 12,000 feet. The excellent results obtained by sending 
phthisical patients from Peru into the high valleys of the Andes were 
largely responsible for the selection of a mountain climate for pulmonary 
tuberculosis in Europe and North America. 

Africa : 

In the north the Great Karoo, 2,800 to 6,000 feet, with a long winter 
from April to September, offers a winter climate during our summer. 
The accommodations are said to be inferior. 



RESORTS AT LOWER MOUNTAIN ALTITUDES 

For Spring and Fall 
Switzerland: Montreux, Vevey. Tyrol: Bozen, Gries, Meran. 

For Summer and Sometimes Winter Months 

Mendelpass, over 4,200 feet; Brennerbad, 3,900 feet; Gossenpass, 
over 3,000 feet; Semmering, over 3,000 feet; Neu-Schmecks, Zakopane, 
Neumarkt, Aussee. Les Avants, 3,232 feet, hot in summer, excellent 
hotel open in winter. Milder winter than at Davos. Protected by 
mountains from north and east winds. Any place in the country with 
plenty of trees. Interlaken, 1,600 feet ; Gleichenberg, 900 feet ; Reichen- 
hall, 1,400 feet; Velden and Portschach and Millstadt, 1,800 feet. 

Arizona : 

Fort Phcenix, 1,080 feet. 

Tucson, 2,400 feet. Very hot summers, dust showers in winter, beau- 
tiful scenery. 



PHTHISIS 173 

California : 

Redlands, 1,350 feet. Hot, dry in summer, noted for its orange 
groves. 

South Carolina: 
Ashville. 

New York: 

The Adirondacks. — The Adirondack Cottage Sanatorium, Saranac 
Lake, 1,650 feet, a worthy monument to the discernment, intelligence, 
and industry of Dr. Trudeau, is largely responsible for the popularity 
of the Adirondack range in the treatment of pulmonary tuberculosis. It 
is planned for patients who cannot afford to pay more than $5 a week, 
and who are in the very early stages of pulmonary tuberculosis or are 
at least favorable types; its capacity in summer is 100, 112 by use of 
tents. Other sanatoria: Sanatorium Gabriel, Paul Smith's, 2,000 feet; 
capacity, 70; $10 to $18 a week; Stony Wold Sanatorium, capacity, 70; 
$7 a week; Lake Kushaqua, nine miles from Paul Smith's. Raybrook, 
State Hospital; capacity, 120. Without much sunshine, with slightly 
sandy soil, and cold dry winters, the Adirondacks owe almost as much of 
their fame as a resort for tuberculosis patients to the advantages result- 
ing from sanatorium treatment as to the climate itself. The summers 
are apt to be hot, the nights usually cold. Camp life, moderately good 
fishing, and some hunting add considerable attraction. 

Sullivan County. — The establishment of the Loomis Sanatorium at 
Liberty emphasizes the advantages of the dry air on the southern slope 
of a range of hills in Sullivan County; 2,300 feet; capacity, 140; $10 
to $35. 

Maine, New Hampshire, Vermont: 

Moosehead Lake, the Rangley Lakes (1900 feet), the White and the 
Green Mountains offer especially favorable climatic features for patients 
with pulmonary tuberculosis who are in good enough condition to do 
well with active outdoor exercise, who do not require sanatorium treat- 
ment, or who for some reason may be unduly depressed by association 
with persons suffering from their own malady. In some of the smaller 
towns very comfortable accommodations can be obtained at low rates. 
The disadvantages are the difficulty in obtaining proper medical super- 
vision and the lack of sanatorium treatment. 

Massachusetts : 

The Berkshire Hills have been selected for many patients who do 
not stand so rigorous a winter as that of the Adirondacks. The accom- 



174 DISEASES OF THE RESPIRATORY TRACT 

modations, especially at Lenox, are excellent. It is too warm, there is 
too much moisture, and the soil is too full of clay to make the climate 
ideal during the summer months. 

The Sharon Sanatorium, at Sharon (350 feet, capacity 21, $5 a 
week), has demonstrated the effect of sanatorium treatment in a climate 
only moderately favorable. It is sheltered on the north and northwest 
by thick woods. Massachusetts State Hospital at Rutland (1,000 feet, 
capacity 250, $4) was the first state sanatorium to be established in the 
United States. The buildings are on a southern slope, protected on the 
northwest by wooded hills. 

LOW ALTITUDES 

European 

Damp. — Lake of Garda, Arco, Lake Como, Lake Maggiore, Goritz, 
North Shore of Lake of Lucerne. 
Dry. — Egypt, Biskra. 
Moderately Damp. — Lake Lugano. 

American 

Damp. — Florida and Gulf States, shores of the Great Lakes. 

Dry. — Arizona, New Mexico. 

Moderately Damp. — Georgia: Summerville and Thomasville (330 
feet). South Carolina: Aiken (565 feet) and Camden (200 feet). These 
four have become favorite winter resorts for people of means. The 
winters are mild, the soil is sandy, pine trees abound. There are excel- 
lent accommodations, pleasant society, encouragement for outdoor life. 
Lakewood, N. J., in a sandy pine belt, is especially favorable for con- 
sumptives who cannot be sent far from New York. The place has be- 
come so favorite a fashionable resort during the fall, winter, and spring 
that the hotel accommodations are particularly good. 

Moderately Dry. — Texas, inland Southern California, Minnesota, Da- 
kota, Nebraska, Kansas, Winnipeg. 

Dry and Warm. — With the Pacific Ocean and its great current on 
one side and a range of mountains succeeded by high plateaus on the 
other, California, or perhaps more accurately Southern California, is 
noted for its mild winters, cool summers, and abundance of sunshine, 
high humidity, and summer fogs. Individual variations depend upon 
the latitude, proximity to the coast, and situation with respect to the 
ranges of mountains running parallel with the coast line. Below Point 
Conception, halfway between San Francisco and San Diego, the climate 
is distinctly milder than above it, the mountain ranges shutting out the 



PHTHISIS 175 

northerly winds. The climate of California is especially favorable for 
people with moderate vitality. They find an opportunity to interest 
themselves in out-of-door occupations, such as fruit growing. The ob- 
jections for consumptives are in summer the dryness, dust, and wind; 
in winter the high degree of humidity, severe cold winds, and the dif- 
ference between sunshine and shade. 

San Diego and Coronado Beach, in the extreme southwest corner of 
California, have the mildest climate and most equable temperature in 
the state, milder and with less humidity than either Cannes or Men- 
tone. There is an excellent hotel at Coronado Beach. 

Los Angeles, 283 feet, fourteen miles from the coast, with a good 
deal of clay in the soil, is warmer in summer and colder in winter, with 
less humidity, fogs, and winds than the two above. It is more or less of 
a business center. The best season is from November to May. 

Pasadena, 1,000 feet, twenty miles from the coast, is like Los Angeles, 
though with less fogs and a more inland climate, sandy soil, excellent 
hotels. 

Santa Barbara, fifty miles south of Point Conception, one mile from 
shore, is protected from the north winds and suitable for summer and 
winter; the climate is similar to that of San Diego. There are two 
excellent hotels and very capable physicians. 

Moderately Warm and Damp. — Examples of the moderately warm 
and damp coast climate are Algiers, Cadiz, Alicante, Malaga (in Spain), 
Palermo, Catania, all of which have a very even climate; the Ligurian 
coast (Nervi, Spezia, Rapallo, Viareggio, and Santa Margherita), Pegli 
on the Riviera, the island of Lussin, the Gulf of Quarnero (Abbazia), 
Lovrana, Corfu, Ragusa, and the region around Venice. The resorts on 
the Adriatic are not, however, suited for winter residence on account 
of the cold, dry wind coming down from the high mountains. They are 
suitable for the spring and autumn and even for summer, but in Janu- 
ary and February have an irritating effect on the respiratory mucous 
membrane. The others are too relaxing in summer, but are suitable 
for many patients all through the winter. 

Moderately Cool and Damp. — The moderately cool and damp coast 
climate is found on the islands and coasts washed by the Gulf Stream : 
England, France, Norway, etc. The resorts on the North Sea, and to 
some extent on the Baltic, come under this head, but none of them are 
important as far as the treatment of pulmonary tuberculosis is con- 
cerned. 

Monterey, eighty miles from San Francisco, on Bay of Monterey, a 
winter resort for Easterners, and a summer resort for San Franciscans, 
is fairly protected from the winds, and offers a large, well-kept hotel. 
13 



176 DISEASES OF THE RESPIRATORY TRACT 

Nantucket, Block Island, Cape Cod, are excellent examples of 
island climates. Some patients with tuberculosis, notably children 
with joint and glandular tuberculosis, do extremely well there, especially 
during the summer. 

Antiseptic Treatment 

Thus far we have discussed only the means of strengthening 
the patient and making him more resistant to the disease. This is 
not all that needs to be done, for we have at our command agen- 
cies, some of which make the tissues less habitable for the bacilli, 
and others which overcome the symptoms produced by the 
disease. 

Inhalations. — First of all, we would mention sprays and nebuliz- 
ers and inhalation respirators which enable us to put finely divided 
oils and vapors as far as the bronchi. Whether or not these vapors 
reach the alveoli is uncertain, but their influence on the mucosa 
of the air passages is certainly good in that it renders these pas- 
sages more antiseptic, helps remove the accumulations of excre- 
tions, and soothes the abraded surfaces. The inhalation chambers 
of the sanatoria are the most efficient, because more successful in 
saturating the patient with the vapors. In these rooms the patients 
sit and read or amuse themselves for an hour or more at a time, all 
the time breathing an atmosphere charged with antiseptic oils 
and vapors. Next to these inhalatoria in efficiency come the nebu- 
lizers, with which a patient may sit and inhale the vapor through 
tubes for ten or fifteen minutes at a time. Then come the inhala- 
tion respirators, which consist of perforated metal chambers shaped 
to fit over the nose. These contain the volatile mixtures, and the 
patient, by wearing one almost constantly, manages to secure 
enough of the drug to have a positive effect on the air passages. 

The mixtures used for inhalation may be illustrated by the fol- 
lowing prescriptions: 

^ Iodof ormi gr. xxjv ; 

Creosoti puri TT\, jv ; 

Olei eucalypti HI viij ; 

Chlorof ormi TT\, xlviij ; 

Alcoholis et aetheris q. s. ad 3j v. 

M. f. inhal. (Robinson). 



PHTHISIS 177 

IJ Tct. lodi. aetherialis 

Acidi carbolici aa 3i j ; 

Spts. vini rectificati ad §j. 

M. f. inhal. (Coghill). 

By combining sedative drugs, such as chloretone, with the anti- 
septic agents, one secures relief from the troublesome throat irri- 
tations so common to consumptives. Menthol is another drug of 
this type that is worth using. One may use as a base for such 
mixtures, when designed for compressed-air nebulizers, the recti- 
fied petroleums or cotton-seed oils. The following formula illus- 
trates this type of sedative, but antiseptic, mixture : 

^ Chloretone 1.0 gram. 

Camphor 2.5 grams. 

Menthol 2.5 " 

Oil of cinnamon 0.5 c.c. 

Liquid petrolatum 93.5 " 

Another but more irritating mixture, one therefore designed 
for air passages that need stimulation, is the following : 

^ PI. ext. cubeb 60 tn. ; 

Fluid tolu, soluble 60 ni ; 

Tct. iodin 60 TT\. ; 

Spts. camphor 60 HI ; 

Carbolic acid 60 gr. ; 

Glycerin 1^ fl. oz. 

Alcohol sufficient to make 4 fl. oz. 

The drugs used in consumption should be either directly 
stimulant to the body or else antiseptic. Of the former type, 
we have strychnin or nux vomica; of the latter type, creosote or 
guaiacol; and partaking somewhat of the character of each type, 
the iodids and mercury. 

Strychnin is probably one of the best drugs to use in consump- 
tion in that it stimulates the reflex arcs, and thus increases all the 
bodily powers, such as respiration, digestion, and circulation. It 
should be given at regular intervals, probably -fa to fa of a grain 
dispensed in the form of the tablet triturate every six hours for an 
ordinary case. In cases of weak digestion, it is probably better given 



178 DISEASES OF THE RESPIRATORY TRACT 

as the tincture of nux vomica, in doses of ten drops three or four 
times a day, because in this form it exhibits more of the local stimu- 
lant effect on the gastric mucosa than in the form of the alkaloid. 
Barton Lisle Wright, of the United States Navy, has found that 
deep (intramuscular) injections of mercury have proven more 
beneficial than any one type of treatment. His method should 
therefore be tried in all available cases. His summary of the tech- 
nique is as follows : 

The preparation of mercury used is hydrargyrum succinimidum. 
Just before the injections are to be given distilled water is boiled for 
at least twenty minutes. A solution is then made so that 0.64 c.c. (til x) 
will be equivalent to gram 0.013 (gr. £) of mercury succinimid. The 
syringes and needles are boiled for twenty minutes. Glass syringes and 
platinum or gold needles should be used whenever possible. 

The skin of the patient's buttocks is scrubbed with hot water and 
tincture of green soap, then washed with alcohol, followed by ether, and 
this in turn by a solution of bichlorid (1: 3,000). The surgeon's hands 
are prepared as for any operation and sterilized rubber gloves are worn. 
The patient being in a prone position on the table, the needle is driven 
deeply into the muscle tissues by a quick downward plunge. If no blood 
escapes from the butt of the needle, the syringe is put in place and the 
drug injected. If blood escapes, a vein has been punctured, and the 
needle is therefore withdrawn and inserted at another place. 

Begin with -^g- grain of mercuric succinimid, give injections every 
other day, slowly increase the dose until a slight tenderness of the gums 
or a slight diarrhea is produced, then reduce the dose until these symp- 
toms are overcome, and continue the injections until thirty have been 
given. 

Then rest for two weeks; at the end of this interval of rest resume 
injections, using the dose used at the last previous injection, and con- 
tinue upon this dose as long as the patient continues to improve up to 
thirty injections; if any untoward symptoms arise or the patient does 
not appear to be doing well, reduce the dose or alternate injections of 
mercury with injections of arsenious trioxid, -^ grain, and ferrous 
citrate, ^ grain, recommended by Harris, of Providence, R. I., for a 
short time, or arsacetin 1 to 7 grains. 

Each series of injections to consist of thirty, with two weeks of rest 
intervening. As treatment progresses, smaller doses of mercury are 
required. At the end of one year's treatment, a rest of from two to 
three months should be given, when, if the patient is not cured, treat- 
ment should be resumed. 



PHTHISIS 179 

When the dose is too large, in addition to the symptoms of mercu- 
rialization, any one or all of the following may be observed: Rise in 
temperature, loss of weight, gastric disturbances, excessive increase in 
cough and expectoration, angina, or an ulcerative stomatitis. Any of 
the above symptoms being present calls for a reduced dose. 

The initial injection, if the dose be £ grain of mercuric succinimid 
or | grain of the bichlorid, is almost invariably followed by a rise of 
one half degree to one and a half degrees of temperature within three 
to five hours. It has often seemed that this feature may be of diag- 
nostic value. 1 

The stimulation of the metabolism is best carried on by means 
of the iodids or other derivations of iodin. Sometimes iodoform 
in one-grain doses (in gelatin capsules) is given, but this seems 
to have a rather deleterious effect on the digestive tract, and fre- 
quently must be laid aside in favor of one of the iodids. Probably 
in the case of young patients the syrup of hydriodic acid would 
be better than either potassium or sodium iodid, giving a teaspoon- 
ful one half hour before meals. The effect of this drug is syner- 
gistic with strychnin, in that it increases the catabolic processes. 

Guaiacol and creosote have been used for a long time in pul- 
monary complaints, probably because they are excreted through 
the mucous membrane of the bronchi and exercise there an anti- 
septic effect. It seems to me rather better for the digestive tract if 
guaiacol be exhibited by rubbing into the skin (in fifteen-drop 
doses) three times a day. Guaiacol is more readily absorbed when 
rubbed in over the abdomen than over the chest wall, consequently 
this point of application is more usually chosen. If the guaiacol 
is rubbed in combined with an equal quantity of olive oil, it is less 
likely to irritate the skin than when used pure. 

To illustrate a conventional method of combining the drugs 
used in consumption, we quote the following formula, put on the 
market under the name " volesan ": 

Creosote carbonate 5 gr. 

Heroin 2V " 

Camphor 1 " 

Balsam tolu 4 " 

M. f. caps, gelat. no. I. Sig. One capsule t. i. d. 

1 From the Navy Medical Bulletin. 



180 DISEASES OF THE RESPIRATORY TRACT 

In commenting on this, we would point out that heroin should be 
given only when needed to depress the cough centers, therefore, 
for only a day or two at a time ; hence any such combination as the 
above could be used only for a short time, and then the prescrip- 
tion must be changed to meet the new conditions. Therefore, in 
general, in phthisis, we should give individual drugs and vary 
them as needed. 

Tuberculin. — The most direct attack on the disease would be by 
using the sera of animals immunized to tuberculosis; or, next, 
by vaccinating the patient with weakened and graduated toxins 
from the bacilli themselves in order to develop antibodies in the 
patient's own blood. We have not yet succeeded in immunizing 
animals to tuberculosis, and therefore cannot use the first method ; 
and as for the second, it has been in experimental use since Koch 
worked out a tuberculin in 1890. But the inoculation of the pa- 
tient with tuberculin is still in the questionable stage and should 
not be attempted where one does not have adequate laboratory 
facilities for keeping watch of the opsonic index and regulating 
very carefully the surroundings of the patient. Trudeau in the 
Adirondacks has followed out the treatment of consumption by 
tuberculin for some fifteen years, and his reports are very inter- 
esting and very encouraging. Nevertheless, one should remember 
that he used everything that everyone else does in the treatment 
of consumption, plus the tuberculin. 

As to the pharmacology of tuberculin, I quote the following 
from Sollman's " Text-book of Pharmacology ": 

The original tuberculin from Koch is a sterile glycerin extract of the 
bodies of tubercle bacilli. Its injection has no effect on normal animals, 
but even very minute doses cause an intense reaction in tuberculous 
animals. This is shown by the production of fever, and by acute in- 
flammatory changes about the nodules. This may lead to the conversion 
of the nodule into fibrous tissue and may thus effect a cure; on the 
other hand, it may cause necrosis, and lead to a further dissemination 
of the tuberculous process. It may be of benefit in lupus and in tuber- 
culous joints. For this purpose, gradually increasing doses are injected 
hypodermically into the back. It is well to begin with j^qT c - c -> m " 
creasing by y-g-W c.c. until -%^-$ c.c. is reached; it is then increased by 
^-J-g- c.c. until yJ-q c.c. is reached. Larger additions may then be made. 
The total dose should not exceed T ^- c.c, as a rule. The dilutions are 



PHTHISIS 181 

made with 0.5 per cent carbolic acid. In pulmonary tuberculosis its 
use is distinctly dangerous. It should be remembered that it has no 
direct effect on the bacilli. 

The greatest value of tuberculin is as a means of diagnosis. A rise 
of temperature of 1° F. is taken as the index of the reaction. The in- 
jection should be made between 6 and 8 p.m., and the temperature on 
the next day taken every three hours. (The normal temperature should 
have been recorded at the same intervals for two days previously.) The 
first injection should be y^§-^- c.c. for adults, WoT ^° Wo "o c - c - ^ or cm l~ 
dren. If there is no reaction, another injection of ^-J-g- c.c. (for children 
Wo~7 t° toVtt c - c -) ^ s ma de, and if necessary a third injection of t ^-q 
c.c. (for children yoVo *° "2~oS")- When given in this guarded manner 
there is practically no danger. A positive reaction is not quite distinc- 
tive since it is sometimes seen in other affections. The test is also 
widely used for the detection of tuberculous cattle. Another form of 
the tuberculin (Tuberculin R.) has been prepared by the extraction of 
cultures grown on solid media. It is somewhat milder, but no more 
successful, and it has been found to contain living bacilli, so that its 
use should be condemned. 

Symptomatic Treatment 

Fever. — As we have noted elsewhere, we believe that antipy- 
retics should not be used unless the high temperature is damaging 
the patients more than the antipyretics would; hence in consump- 
tion we must answer the question of damage before we set out to 
treat the fever. In my own experience I find it rarely necessary 
to treat the fever. In fact, the temperature curve is to me a valu- 
able index as to the success of my general and more positive treat- 
ment; for I find that when the out-of-door life and the cold baths 
with stimulant food and the drugs named above are doing their 
work, the fever disappears ; and furthermore, if the fever does not 
disappear under those conditions, the patient is doomed ; and then 
the therapeutic indication is simply to make him comfortable. 
Antipyretics do not assist in combating the disease. 

Of the antipyretics we prefer acetphenetidin in five-grain doses, 
or it may be combined, according to Yeo's suggestion, with the 
hydrobromid of quinin, three times a day. 

In this connection it should be remembered that if creosote or 
guaiacol is being used for its antiseptic effect, it of itself has a 
tendency to depress fever temperatures. Consequently, in those 



182 DISEASES OF THE RESPIRATORY TRACT 

systems of treatment into which gnaiacol enters, other and special 
antipyretics are rarely needed. 

Night Sweats. — These are of two sorts: the critical sweat from 
the daily fever and the sweating of exhaustion. The former occurs 
about midnight or shortly afterwards, and the latter whenever the 
patient falls asleep, be it day or night, early or late. The condi- 
tions under which the patient sleeps have much to do with these 
sweats, and we find fever among patients sleeping in tents less 
frequently than among those sleeping in houses. The amount and 
kind of clothing worn have also their influence, there being less of 
sweating when the hygienic principles discussed above are fol- 
lowed carefully. Furthermore, the early morning cold bath and 
the evening oil rub also do much to prevent the disagreeable sweat- 
ing so common among consumptives. 

When we do need to check the sweats by direct drug attack, we 
prefer to use atropin or its congener, agaricin. The former is 
given in t Jq- grain just about bedtime, and the latter usually three 
times a day in the dosage of T -J-^ grain. 

Needless to say, the exhaustion sweats indicate strychnin, cam- 
phor, or caffein, rather than depressants. Even the inhibitory 
effect of atropin on the vasomotor system savors sometimes too 
much of depression for the patient's good, and in general we would 
say that night sweats indicate a need for a vasomotor tonic or 
stimulant (such as the three just named) rather than a depressant 
or paralyzant, such as Dover's powders or quinin. 

Cough. — Before starting in to check any cough, we must first 
determine whether it is a useful or simply an irritative one. Thus 
patients with considerable sputum are benefited by a coughing 
spell in the morning. It usually clears out the passages and rids 
the patient of throat irritation for several hours. The morning 
cold bath, in which cold water is thrown against the chest and back, 
will stimulate such a productive cough with its attendant deeper 
breathing. The irritative cough or hack should, of course, be 
checked, but checked by stimulant rather than depressant measures. 

Heroin is, of course, the drug upon which we must depend to 
depress the medullary cough center, and we should not hesitate to 
resort to it for a day or two at a time when the patient is going 
about with a constant hack, or is forming a bad coughing habit. 
A dose of T \ grain every three hours is usually sufficient. It 



PHTHISIS 183 

should be given separately from the other drugs in order to facili- 
tate its discontinuance. 

The dry, hacking cough should be treated by stimulant inhala- 
tions; e. g., with a mask, or with a nebulizer, or with steam. In 
general, the most efficient inhalation is steam charged with eu- 
calyptol, and this can be given so easily that one can find no 
excuse for not using it. The steam softens the throat tissues, and 
therefore gets rid of the cause of the reflex. With the nebulizer 
one should use an oily compound, such as that containing menthol 
and chloretone, mentioned above. With the mask one must use an 
alcohol-ether base, for which a prescription is also given above. 

In hopeless cases, where we simply try to make our patients 
comfortable, we use morphin, thus both quieting the cough and 
soothing the mind. 

Vomiting. — Vomiting can occur only when the stomach has not 
been put in order at the beginning of our course of treatment and 
the accumulation of mucus in the respiratory passages has not 
been cared for. Its occurrence means, therefore, that we have 
failed to carry out all the necessary points in hygiene. 

Our reason for making this statement is that vomiting occurs 
only when mucus either collects in the respiratory passages and 
the stimulation of the hot food in the stomach excites the dia- 
phragm to renewed exspiratory efforts, thus bringing the food out 
of the stomach with the mucus out of the bronchi, or the swallow- 
ing of mucus has brought about an irritative gastritis that needs 
only the entrance of food to set up expulsive spasms. 

When it occurs we need to flush out the stomach either through 
the tube or with mineral waters (better with simple carbonated 
waters), and then prescribe light meals every three hours. We 
should then stimulate the bronchi by using hot and cold fomenta- 
tions to the posterior thorax daily, and by giving inhalations of 
steam charged with turpentine three times a day. 

For a drug to quiet the stomach, bismuth subnitrate (ten 
grains), suspended in four ounces of water, will prove thoroughly 
efficient, but this should not prevent our giving, at the earliest 
possible moment, the gastric lavage, which should be continued 
until the stomach has regained its tone. 

Hemoptysis. — Hemoptysis is usually due to some corrosive proc- 
ess, but may be due to the rupture of varicosities of the lower air 



184 DISEASES OF THE RESPIRATORY TRACT 

passages, and may be simulated by the rupture of a varix in the 
esophagus. In consumption it is rarely fatal, and may even be 
beneficial, hence we should avoid alarming our patients in refer- 
ence to it, and simply teach them to adopt measures of relief when 
it occurs. 

The treatment of hemorrhage must be directed toward facilitat- 
ing the clotting of the blood, and toward preventing such a great 
loss of blood that the patient will be permanently weakened. 
Therefore the blood pressure should be lowered, the action of the 
heart should be slowed and made regular, and at the same time, if 
possible, there should be a local constriction of the vasomotor sys- 
tem to decrease the amount of blood flowing through this part. 
To attain this end, the patient should immediately be laid on his 
back and the tissue around and about the supposed break in the 
vascular system chilled as much as possible. This can be accom- 
plished partly by applying an ice bag to the chest, and partly by 
letting the patient swallow slowly small pieces of ice. Any vol- 
untary movement on the part of the patient will probably set up 
the hemorrhage again, therefore he must be kept absolutely quiet 
and passive for several hours. 

Probably as good a drug as any for the continual oozing from 
a rupture would be styptol, § grain every hour or two for the first 
two or three days. This also has a tendency to constrict the capil- 
laries. 1 Morphin also has a beneficial effect in quieting the pa- 
tient and thus benefiting the condition. Thus Dr. Sloan says: 
11 The opiates have been more effectual than anything else in my 
experience. ' ' 

The matter of constriction of the arteries has a wider influence 
than that simply of closing up the break in a capillary, for it also 
increases the blood pressure, and this increase in blood pressure 
would tend to break open the capillaries again; hence in hemor- 
rhage the ideal thing would be to apply locally a locally acting 



1 In addition to the vasoconstriction by means of chilling the tissues, we may 
try the effect of drugs to increase the clotting power of the blood. In this mat- 
ter, experimentation and clinical experience have not yet reached an agreement, 
and some of the drugs (e. g., calcium lactate) used in a routine way by many 
practitioners seem to have no effect when tried out under laboratory conditions. 
Thus the use of calcium lactate (dose 15 grs. t. i. d.) has not proven efficient in 
animal experiments (Addis) in shortening the coagulation time of the blood. 



PHTHISIS 185 

vasoconstrictor, and systematically a drug that would lower the 
blood pressure elsewhere. Thus, if one could apply adrenalin 
chlorid locally and the nitrites generally, one would quickly stop 
the leak, but only in the most severe cases is there danger of a 
fatal issue, hence the question of the ideal is largely an academic 
one. 

Aconite and veratrum viride are given by many practitioners in 
cases of hemorrhage to reduce the blood pressure. For that pur- 
pose the former is given in doses of one drop of the tincture every 
hour until the effect is manifest. The latter is used in similar doses 
of the fluid extract. 

Probably nothing is quite so alarming to the patient and his 
friends as the sudden gush of blood from the mouth. This alarm 
may have a distinctly worse effect on the patient's condition than 
the hemorrhage itself, hence the first duty of the physician is to 
reassure the patient and his entourage that nothing horrible is 
about to occur. On the other hand, the friends should be kept 
busy doing the few necessary things that need doing — preparing 
cracked ice, etc. — in order that they may not stand about bewail- 
ing the condition. 

The treatment should be continued for two or three days at 
least, and then the drugs chosen should be those which, like cal- 
cium, tend to form solid scar tissue. In addition, the saturation 
of the air passages with iodin and the use of mercury should be 
adopted more vigorously than before, in order to decrease, if pos- 
sible, the rapidity of the ulcerative process. 

But that there is some value in giving lime salts in such cases cannot be denied. 
Hence we may give calcium hypophosphite for its systemic tonic effect as in the 
following prescription: 

1^ Calcis hypophosphitis gr. iij ; 

Glycerini ttl xx ; 

Tincturse quassise rr^ x ; 

Syrupii aurantii 3 ss; 

Aquae q. s. ad § ss. 

M. f. dosis. Sig. Three times a day, one hour after food. (Yeo.) 

Or, better still, give relatively large doses of calcium lactate and give also a 
nucleo-albumin such as thyroid extract. Of the former we should order 20 
grains every four hours. Of the latter, 3 grains three times a day on an 
empty stomach. 



186 DISEASES OF THE RESPIRATORY TRACT 

Diarrhea. — When caused by intestinal ulceration, the diarrhea 
of phthisis is extremely difficult to check. When, however, it is an 
accidental complication, it can be handled by the usual methods. 
For this we prefer the albuminates of tannin — tannalbin, tannigen 
— or the tincture of kino or krameria. 

On the other hand, the British writers have more complicated 
prescriptions. For instance, for intestinal ulceration with diar- 
rhea Yeo recommends: 

5 Fluid extract coto rrt lx ; 

Tincture cardamon co lU lx. 

Mix and triturate slowly with 

Mucilage of acacia 3iij ; 

Simple syrup oij ; 

Finally, add enough water to make §vj. 

Give one tablespoonful of the mixture as needed. 

For diarrhea accompanied by pain, we of course use the tinc- 
ture of opium in ten- to fifteen-drop doses. Or, if we prefer mix- 
tures, we may use the following: 

IJ Ext. opii gr. jss ; 

Syrup aurantii ov; 

Elixir gentian, glycerinat., N. F q. s. ad §v. 

M. f. mist. Sig. One teaspoonful every two hours. 

Complications. — The chief complications of phthisis are laryn- 
geal tuberculosis, pleurisy, pneumothorax (or pyopneumothorax), 
and anal fistula. 

Laryngeal tuberculosis should be actively treated not only by 
inhalations and hygienic regulations (chief among which is com- 
plete vocal rest), but also by expert local surgery. Thus the punch- 
ing out of the ulcers, or their cauterization with lactic acid (five 
to forty per cent) has rendered good service ( Casselberry, Journal 
of the American Medical Association, for August 7, 1909, p. 436), 
except in the specially nonresistant cases where the body shows no 
ability to react against the disease. 



PHTHISIS 187 

If pleurisy causes considerable pain, it requires the bandaging 
of the chest and the application of heat (thermophore). As a 
general rule it is wiser not to aspirate pleuritic effusions in tuber- 
culosis, but to put the whole emphasis on the systemic treatment. 

Pneumothorax, if it causes dyspnea, should be tapped (asep- 
tically) and enough air removed to equalize the pressure, and the 
wound sealed with adhesive plaster or collodion. 

Experience is in favor of not interfering even with a pyopneu- 
mothorax except where the dyspnea or danger to life absolutely 
demands it. Then it should be done surgically with a wide open- 
ing and thorough irrigation. 

What should be done in case of a fistula in ano depends upon 
the patient's general condition. If he is improving, it should be 
treated according to the best surgical methods. If, on the other 
hand, he still has fever, or is growing worse, it should be let alone 
and palliative treatment, with phenolated camphor, etc., should 
be used. 

In undertaking the treatment of a case of consumption, one 
should protect himself by demanding that the patient give him 
at least six months of absolute obedience. Nothing of any per- 
manent value can be accomplished under that length of time. To 
have a patient go to a sanitarium, or to change his climate for a 
month or two, is worse than useless. In the matter of change of 
climate, this principle should govern : If the patient can change his 
climate permanently and live in one better adapted to him, it is 
the best thing he can do ; but if he can go away from home only for 
a short period of perhaps one or two years, then it would be better 
for him to stay at home and take open-air treatment in the very 
climate in which he must live. While the dry Western and South- 
ern climates of the United States seem to be best adapted to the 
treatment of this disease, nevertheless successful work has been 
done in Massachusetts and New York, where the climate is any- 
thing but equable. 

Finally, as Osier states, ' ' benefit is usually a matter of months, 
complete arrest a matter of years, absolute cure a matter of many 
years. ' ' 



CHAPTER IV 
DISEASES OF THE DIGESTIVE TRACT 

THE MOUTH 

Stomatitis 

We are in danger of forgetting that the physician should have 
charge of the mouth, as well as other parts of the body. The den- 
tists, on the other hand, are realizing that the average physician 
knows little or nothing of oral medicine, and are seeking degrees 
in medicine in order to be able to handle adequately the neglected 
field. 

The daily cleansing of the teeth and mouth is an absolute 
essential to life under modern conditions. This includes the keeping 
of the teeth in good repair, so that at all times the patient may 
have a good organ of mastication. 

At least once a day the teeth and gums should be brushed with 
a medium hard brush, brushing with water and a powder or paste 
that (1) cleanses, (2) oxidizes organic deposits, and (3) sterilizes. 
The mechanical part of brushing the teeth is difficult and demands 
both energy and patience. It is an art that should be cultivated. 
The solution of peroxid of hydrogen should also be used now and 
then for gargling. 

The following is an illustrative formula for a tooth powder: 

^ Strontii perborat 6.00 5jss ; 

Saccharin 0.20 gr. iij ; 

Os sepiae pulv 4.00 3j ; 

Saponis pulv 4.00 3j ; 

Calcii carbon, precip 30.00 §j ; 

Olei menth. pop 1.00 gtt. xv. 

M. f. pulv. (Potter). 

188 



THE MOUTH 189 

It is well to have a good dentist examine the teeth once or twice 
a year, to fill cavities and to prevent damage from deposits of 
tartar and similar results of neglect of the daily toilet. 

Inflammations of the month may be due to (1) mechanical 
causes, such as injury from broken teeth, hard particles of food, 
etc.; (2) physical causes, such as hot food; (3) chemical causes, 
such as caustics and other poisons introduced by mistake; and 
finally (4), bacterial agents that reach the membranes either with 
the food or with the air through the nose. The membranes of the 
mouth are so resistant that unless either the bodily resistance is 
lowered or mechanical or physical or chemical injury precede, bac- 
terial infection can hardly take place. Hence, in nursing infants 
among whom stomatitis is particularly frequent, we must look to 
the systemic condition coincidently with our local treatment. With 
older patients who are also subject to the mechanical injuries due 
to bad teeth and hard food, we must correct the mechanical condi- 
tions, as well as the bacterial. 

Acute Stomatitis. — In the acute stomatitis of children, unaccom- 
panied by ulcers or bacterial growths, we need first of all to remove 
any irritating agencies such as hard nipples (if the patient be a 
nursling), irritating teeth, etc. Then we should give food that is 
nonirritating in temperature as well as in constitution. Cool or 
cold food will be grateful to such patients. The mouth should be 
frequently washed out with cool water — boiled water to which 
twenty-five per cent of glycerin has been added will do as well as 
anything. The membranes should not be brushed or rubbed so 
hard as to irritate them. 

If ulcers occur, they should be touched with the silver-nitrate 
stick. Cysts should be incised and their walls touched with either 
the silver nitrate or pure carbolic acid (followed by alcohol). 

Chronic Stomatitis. — Chronic stomatitis is more often due to 
gastrointestinal and constitutional disturbances than to local con- 
ditions. Hence the treatment, while not neglecting the local meas- 
ures such as cleansing and irrigating the whole oral cavity, should 
be mainly directed toward putting into order the whole body. The 
blood should be examined for evidences of anemia, and if there 
be no patent gastrointestinal disorder, the analysis of the gastric 
contents after a test meal should be made, and if necessary also 
an examination of the feces for parasites and defects of pancreatic 



190 DISEASES OF THE DIGESTIVE TRACT 

digestion. When an anomaly is found, it should receive adequate 
treatment. 

For the local disorder, treatment along the principles already 
laid down should be given. The teeth should be brushed after each 
meal, the mouth and pharynx should be irrigated daily with an 
antiseptic solution such as the liquor antisepticus N. F., and ulcers 
touched as often as needed with pure carbolic acid and alcohol. 
If the membranes seem edematous and relaxed, the application of 
an astringent such as a five-per-cent solution of tannin in glycerin 
should be frequently made. 

Stomatitis from Thermal or Mechanical Injury. — Acute inflam- 
mations due simply to thermal or mechanical injury should be 
treated by stopping all food by the mouth if necessary; then the 
mouth should be kept antiseptic by frequent irrigation with the 
liquor antisepticus. The pain may be relieved by cocain (two per 
cent), menthol (five per cent), in glycerin and water, or the use 
of small pieces of ice. Of course, the subcutaneous use of morphin 
may be necessary, and should be resorted to if the above simpler 
remedies are not sufficient. 

Thrush needs to be treated by rubbing out the patches with 
strong solutions of sodium bicarbonate. This brushing or rubbing 
should be done every two hours, care being taken not to injure 
the adjacent membrane. It is best done with a piece of soft linen 
wrapped about the finger tip. The reaction of the mouth should 
be made alkaline by frequent irrigation with alkaline fluids, such 
as the following mixture: 

^ Sodii bicarbonatis Sviij ; 

Sodii biboratis Sviij ; 

Sodii benzoatis gr. xx ; 

Sodii salicylatis gr. xx ; 

Eucalyptolis gr. x ; 

Thymoli gr. x ; 

Mentholis gr. v ; 

01. gaultheriie gtt. vj ; 

Aqme o xv J- 

The disease is contagious, but may be prevented from spreading by 
thorough cleanliness, especially of nursing bottles and nipples. 
Calomel given in doses of one tenth grain as frequently as the age 



THE MOUTH 191 

of the child permits will usually care for the intestinal condition. 
It may be necessary to feed the child with a tube through the nose 
while the mouth is sore. 

Aphthous Stomatitis (Herpetic, Vesicular). — Aphthous stoma- 
titis should be treated by touching the ulcers with silver nitrate 
(two- to ten-per-cent solution), and by frequent swabbing of the 
membranes with one half to one per cent potassium permanganate. 
Here also the systemic condition demands the first thought — e. g., 
the excessive use of sweets in the food should be controlled. Diar- 
rhea and constipation should be treated by alkaline drugs (e. g., 
bismuth or magnesium sulphate). 

Ulcerative Stomatitis. — Ulcerative stomatitis requires the use of 
strong solutions (three per cent) of potassium chlorate. This is 
somewhat painful and is toxic. Loose teeth must be extracted and 
suppuration treated with the full strength of the commercial solu- 
tions of hydrogen peroxid, injected into the abscesses with a good 
syringe. Ulcers may be treated with silver nitrate (use cocain 
before making the application ! ) and a soothing mouth wash of 
glycerin and borax may be at hand for the patient to use as needed. 
For instance, the following may be employed: 

I£ Acidi salicylatis oss ; 

Alcoholis 5iij ; 

Aquag camphorae gij ; 

Glycerini ad gviij. 

M. f. lotio. 

The internal administration of potassium chlorate (children, 2 
grains ; adults, 10 to 20 grains t. i. d. in syrup and water) must be 
carefully supervised lest it poison the patient (see notes on reme- 
dies), but it seems worth while because of the antiseptic influence 
exerted by the drugs as it is being excreted through the saliva. 

Mercurial Stomatitis. — Mercurial stomatitis requires prophylac- 
tic treatment in that the mouth should be put into good condition 
before mercury is given. Solutions of potassium chlorate and 
hydrogen peroxid need to be used thoroughly and frequently as 
soon as the red line appears. The mercury must, of course, be 
stopped. Elimination needs to be stimulated. Thirty to sixty 
grains a day of potassium chlorate may also be given internally. 
14 



192 DISEASES OF THE DIGESTIVE TRACT 

The diet needs to be such as requires no mastication, and should 
be as nutritious as possible — ground meats, strong soups, eggs, etc. 

Scorbutic Stomatitis. — Scorbutic stomatitis should not be treated 
with potassium chlorate, because the stomatitis disappears as soon 
as the general condition improves. Simple antiseptic and soothing 
irrigations will be sufficient for the local treatment. 

Pyorrhea Alveolaris. — Pyorrhea alveolaris is an infection by a 
variety of staphylococcus. It needs surgical (dental) attention for 
cleansing out the ulcers and abscesses. The use of vaccines 
(Hecker) constitutes the most active treatment of the disease. The 
frequent and thorough brushing of the teeth constitutes both the 
best prophylaxis and an excellent succedaneum. 

Noma. — Gangrenous stomatitis and noma depend for their de- 
velopment upon a very debilitated condition of the system. The 
moment gangrene appears the patient should receive diphtheritic 
antitoxin (see diphtheria) and the local necrotic tissue should be 
thoroughly cauterized under chloroform anesthesia, applying the 
Paquelin cautery so as to include all the necrotic tissue — that is, 
cut into healthy tissue. It is impossible to avoid disfigurement 
and we are satisfied to save the patient's life; hence the treatment 
must be radical and early. After the cauterization the tissues 
must be irrigated every two hours with strong solutions of potas- 
sium permanganate or hydrogen peroxid, and gauze moistened in 
formalin 1 : 2,000 should be laid over the outside of the gangrenous 
patch to stop as much as possible of the fetor. Strychnin in full 
doses should be given every four hours, and every means resorted 
to for raising the constitutional resistance of the patient. The diet 
consists of eggnogs and other rich liquids, administered by the 
nose if need be. The child should be kept from lying on its back 
in order to avoid the swallowing of the putrid matters and the 
consequent inhalation pneumonia. 

Geographical Tongue. — Geographical tongue, or eczema of the 
tongue, is a chronic and obstinate affection that, however, does 
not do much damage. The Roentgen ray seems to be the only 
means of influencing it permanently. It is due to some chronic 
irritation, such as excessive smoking; hence the first step in its 
treatment is the removal of such irritation. The disorder is so 
harmless that were it not for the cosmetic effect it could be safely 
neglected. 



THE ESOPHAGUS 193 

Leukoplakia Oris. — Leukoplakia oris is generally charged up to 
the account of syphilis, but appears to have other causes as well. 
It yields best to painting with the U. S. P. tincture of iodin, with 
coincident systemic treatment with mercury and the iodids. For 
instance, the intramuscular injection of mercury succinimid (one 
fifth grain on alternate days) with fifteen to twenty drops of the 
saturated solution of potassium iodid three times a day, usually 
clears up the patches. Smoking and other throat irritations must 
be given up during treatment. Should papillomata develop, they 
should be removed by the knife and the wound exposed to the 
Roentgen ray. 

THE ESOPHAGUS 

Inflammation of the Esophagus 

Inflammation of the esophagus is practically always due to a 
burn (e. g., carbolic acid, lye) or mechanical injury. The primary 
indication is therefore for rest, relief of pain, and prevention of 
(1) sepsis and (2) stricture. 

The rest is obtained by giving little or no food by the mouth. 
What is given must (like milk) be entirely nonirritant. In gen- 
eral, it is better to use nutrient enemata until the raw surfaces be 
healed over. (For the details of this procedure, see page 203.) 
The pain is relieved by demulcent liquids and opium. It is better 
to use opium than morphin (in order to secure its local effect), 
but frequently the patient cannot swallow at the time when relief 
is most needed, so that morphin given with the needle will be 
necessary. When the opium can be used, the following prescrip- 
tion may be employed (Yeo) : 

IJ Ext. opii gr. ijss ; 

Bismuth subnitratis gr. xl ; 

Emulsionis tragacanth SJss. 

M. f. suspensio. Sig. One teaspoonful every hour for pain. 

This serves to relieve pain and prevent irritation, and the con- 
sequent formation of scar tissue. Its effect will be assisted if a 
tablespoonful of olive oil be given t. i. d., or if the patient cannot 
take olive oil, the milk of almonds may be used. Hot fomentations 
externally may be of some assistance. 



194 DISEASES OF THE DIGESTIVE TRACT 

The mouth must be frequently — e. g., every hour — irrigated 
with cold water. This is best done by gargles when the patient 
can carry out this procedure. 

The milk diet should be kept up for several days, and the 
change to general diet made gradually, by using such intermediate 
foods as grain soups, white of egg, etc. 

Stricture of the Esophagus 

When in spite of these prophylactic measures a stricture is 
formed, it requires both local and constitutional treatment. The 
cautious passage of graduated bougies or dilators serves for the 
first, and the giving of potassium iodid (10 grains t. i. d.) or of 
fibrolysin (by the needle 2.23 c.c. on alternate days) for the second. 

But such strictures must be carefully differentiated from the 
stenoses due to malignant growths, pressure of tumors outside the 
esophagus (such as goiter, enlarged mediastinal glands, and aneu- 
rysms), and spasmodic stricture, for each of these needs its special 
treatment. 

Tubage. — For malignant stenoses we may either insert a tube or 
do a gastrostomy. Yeo describes the former treatment as follows: 

Mr. Symonds's method (Charles J. Symonds, of Guy's Hospital) is 
to pass through and retain in the stricture a short funnel-shaped tube, 
the upper expanded part of which rests on the top of the strictured 
portion of the canal. It is passed down to the stricture by means of an 
ordinary conical bougie fitted into the funnel, and after the funnel tube 
is fixed into the stricture the bougie is withdrawn, a strong silk thread 
having been previously fastened to the funnel end of the tube long 
enough to extend beyond the mouth and to be looped over the ear, behind 
which it is fixed by a piece of strapping. These tubes are made of gum 
elastic; they are six and a half inches long, the funnel end is one half 
to three fourths of an inch in diameter; it ends in an ordinary catheter 
end and eye. Mr. Symonds maintains that this tube has proved of the 
greatest service in the treatment of malignant stricture of the esophagus, 
upon which its pressure produces no irritating or injurious effects. It 
is prevented from slipping down through the stricture by the silk cord 
attached to it, as well as by the funnel expansion, and by means of the 
cord it can be easily withdrawn. Its advantages over the long tube pro- 
jecting from the mouth are obvious: it is not unsightly, it does not 
interfere with deglutition in any way, it does not irritate the larynx, 



THE ESOPHAGUS 195 

and it does not cause a constant escape of saliva from the mouth. In 
the first case reported by Mr. Symonds, the patient was kept alive for 
eight months in comparative comfort, and never felt any inconvenience 
from the tubes; the stricture dilated considerably, and on post-mortem 
examination no injurious effect could be traced to its pressure. In the 
later stages of the disease, it was necessary to remove the tube frequently, 
as it became blocked with sputum and food. Life has been prolonged for 
periods varying from four to eleven months by the use of these tubes. 
The tubes usually do not require changing oftener than every three or 
four weeks; Nos. 12 or 14 is the size usually worn. They are durable 
and the same tube and silk have been used for more than three months. 
Mr. Symonds appears to think that the use of these tubes will generally 
obviate the necessity of having recourse to gastrostomy, with its attend- 
ant dangers, and the distress from the excoriation of the skin around 
the external orifice of the gastric fistula. 

When a gastrostomy is done, a tube is left in position through 
which peptonized foods are inserted into the stomach. This pro- 
longs the patient's life and prevents his suffering for considerable 
time. (For the technic, see texts on surgery.) The gastrostomy 
should be done as early as its necessity is foreseen, because it of 
itself requires some resistance and vitality. 

Carcinomatous Stricture. — It is, of course, self-evident that 
esophageal stricture due to carcinoma should not be dilated. Treat- 
ment in such cases can only be that of relieving the pain and feed- 
ing by the rectum, except where a gastrotomy may be done to 
relieve the patient for a short time. 

The mouth may be kept moist by holding in it a swallow of 
water or pieces of ice. The teeth and gums need to be cleansed 
several times a day with hydrogen peroxid or an alkaline antiseptic 
solution. 

The pain calls for morphin, the constipating effect of which 
may be counteracted by using ox-gall enemata. For although no 
food is taken by the stomach, nevertheless the peristalsis must be 
kept up to prevent the absorption of putrefying gastric and intes- 
tinal secretions. The morphin must, of course, be given hypo- 
dermatically. 

Some nourishment can be given by rectal enemata, but hardly 
enough to establish an equilibrium; hence wherever possible a 
gastrostomy should be done and the patient fed with a tube. 



196 DISEASES OF THE DIGESTIVE TRACT 

The food given by the tube should be in finely divided form, 
and usually consists of eggs, milk, soups, etc. Sometimes scraped 
steak, mashed potatoes, and similar foods may be used. Now and 
then a patient is found who insists on taking a general diet, chew- 
ing it and then filling his food syringe from the mouth and in- 
jecting the masticated bolus through the gastrostomy tube into the 
stomach. 

While the stricture is still patent, the patient may be fed by the 
mouth, but necessarily the diet in all such cases must be such as 
can pass the stricture. To illustrate, I quote the following diet 
used by Cohnheim: 

At 7.00 a.m. Lavage and oil treatment. 

Tea, with 125 grams of cream. 

250 grams of milk. 

A soup made of flour, containing 125 grams of cream 

and butter. 
Bouillon with 1 or 2 tablespoonfuls of flour, and 1 

or 2 yolks of eggs with butter. 
Tea, with 125 grams of cream. 
Any kind of soups, made from cereals or milk. 
Bouillon with sago or flour and butter. 

Besides the above, the patient may, if he desires, be given either 
wine, or wine with eggs, buttermilk with koumiss, fruit juices diluted 
with mineral water, fruit and vanilla ice cream, puro sanatogen, soma- 
tose, etc. If the stenosis is slight, semisolids of all kinds, such as 
the finest puree of potato, spinach, carrots, raw eggs, etc., are indi- 
cated. 

In addition, the physician should prescribe a half wineglassful of 
olive oil, one half hour before the midday and evening meals, if the 
patient does not have a repugnance toward it. For patients who cannot 
use the oil, a cup of the milk of almonds may be substituted. Such a 
diet not only maintains the strength of the patient, but may also cause 
an increase in weight if the patient takes the proper physical care of 
himself. I have personally observed, in cases of this kind, an increase 
of ten pounds or more. 

The lavage and oil treatment referred to in the above extract 
is carried out, as follows: 

Lavage and Oil Treatment. — To wash out the esophagus, the physi- 
cian should use an ordinary soft stomach tube, No. 8 (American No. 



7.00 


A.M. 


8.00 


a 


9.00 


« 


11.00 


a 


1.00 


P.M. 


4.00 


a 


6.00 


a 


8.00 


a 



THE ESOPHAGUS 197 

20) about 90 cm. long, the lower end of which contains two lateral open- 
ings. The tube should be introduced to the constricted portion of the 
esophagus, and the stagnating food should be washed out in the follow- 
ing manner : 

A small glass funnel, with a capacity of from 50 to 75 c.c, should 
be connected with the proximal end of the stomach tube, and warm 
water should then be poured into it and the esophagus thoroughly- 
cleansed by alternately raising and lowering the funnel, the greatest 
possible care being taken to remove all mucus and food remnants. Fol- 
lowing lavage, 30 c.c. of warm olive oil should be introduced. The 
deeper the cancer is situated, the more warm water and oil can be 
used. When the carcinoma occupies the upper part of the esophagus, 
the lavage and oil treatment are generally impossible. One hour after 
treatment the patient may be allowed to eat. 

In beginning treatment, the above procedure should be carried out 
daily, preferably before breakfast, and later on every few days. Patients 
are considerably relieved by the lavage and oil treatment, and are, as a 
rule, after a short time able to carry out the treatment alone. 

Enlarged glands, causing apparent stricture of the esophagus, 
would, of course, be treated for themselves by using potassium 
iodid, the X-ray, mercury, etc., according to the nature of the 
inflammation, and if capable of reduction, be influenced by con- 
stitutional remedies. If beyond the reach of drugs, the surgeon 
should be called in. So also aneurysms (q. v.). 

Spasmodic stricture calls for nerve sedatives, such as the bro- 
mids (15 grains t. i. d. in solution) or atropin (hypodermically 
jfo grain t. i. d.). Then hydrotherapeutic measures to tone up 
the body (alternating sprays, drip sheet, massage, etc.) should be 
used. The diet must be nonirritant and mineral waters sufficient 
to keep the bowels freely open must be used. In addition, vigorous 
local treatment may be instituted, as described in the following 
paragraphs on cardiospasm. 

Spasm of Esophagus and Cardia 

Chronic cardiospasm is to be treated mechanically by forcible 
dilation. Probably the best method is that wherein a dilatable 
rubber bag is introduced into the contracted space, and then pres- 
sure exerted under the control of a mercurial manometer. Thus 
Cohnheim says: 



198 



DISEASES OF THE DIGESTIVE TRACT 



This dilatation is easily accomplished by means of a dilatable rub- 
ber bag, such as a condom, fastened over the distal end of a small- 
sized, stiff-walled stomach tube, or an especially contrived rubber 
bag introduced into the cardia by means of a wire stilet or bougie. 

The rubber bag should be 
covered by a silk bag to con- 
trol and limit its amount of 
distention during treatment. 

A mercurial manometer is 
an essential part of the appa- 
ratus by which the physician 
will be able to control the 
amount of pressure used in 
distending the cardia within 
safe limits — namely, six or 
seven pounds. 

The normal cardia cannot 
be safely stretched beyond a 
diameter of 3.5 cm. The silk 
bag which covers the rubber 
balloon should therefore have 
a maximum diameter, when 
fully dilated at a pressure of 
six or seven pounds, of about 
3.5 cm. Early treatments 
should be given with smaller 
sized bags, these being grad- 
ually replaced with ones of 
larger size, at each succeed- 
ing dilation of the cardia. 

Either air or water pres- 
sure may be used to distend 
the rubber bag. 




Fig. 31. — Cohnheim's Apparatus for Dilat- 
ing the Cardia. 



o 

O 



Fig. 32. — Trousseau's Bougies. 



THE ESOPHAGUS 199 

When the contraction is extreme, Trousseau's esophageal bou- 
gies should be used to open the way for the bag and to measure the 
distance from the incisors, as well as the diameter of the passage. 

Another method of dilating the esophagus is that of Plummer, 
described by him, as follows : 

The dilator is made by cementing a rubber-dam balloon to one end 
of a piece of nonelastic rubber tubing in such a manner that the tube 
just passes through the balloon. The end of the tube is closed with a 
rubber plug, and a number of holes so punched that its lumen com- 
municates with the interior of the balloon. A sausage-shaped silk bag 
is drawn over the balloon to preserve its shape under distention. Several 
sizes, five inches in length and varying from three fourths to one and 
one fourth inches in diameter are provided. If the dilator is slightly 
constricted in its middle third, the tendency for it to slip into the 
stomach or esophagus is lessened. A flattened steel wire is used as an 
introducer. Provision for connecting a tube leading to a water tap or 
pump is made. A section of the tube is doubled. One passage is nar- 
rowed by inserting a capillary glass tube, and the other section is pro- 
vided with a stopcock. An altitude gauge is also connected by means 
of a " T " joint. Having previously determined the position of the 
cardia, the dilator is introduced sufficiently far for the cardia to engage 
the balloon at its middle third, and the water turned on at the tap 
until the gauge indicates the pressure of one or two feet. The stopcock 
is now closed and the pressure slowly raised to the required point by 
forcing the water through the capillary tube. The force to be used is to 
be determined by the tolerance of the patient and the results obtained 
from former attempts. The pressure used has ranged from five to 
twenty-five feet, great variation being shown in the ease with which the 
cardia dilates. In one case the cardia contracted sufficiently to cause 
obstruction within a few days after each dilatation, until a pressure of 
approximately fifteen pounds was reached. The reason for the failure 
to obtain satisfactory results by those who have used the mouth to ex- 
pand the dilator is at once apparent. Danger of tearing the esophagus 
is to be avoided by stretching slowly and by having the dilating force 
under such control that it may be instantly released if severe pain indi- 
cates any giving way of the tissues of the cardia. Sudden expansion of 
the dilator, should a tear start, is guarded against by constructing an 
instrument of rigid tubing, filling the dilator with a noncompres- 
sible medium, and having the water supply almost shut off by the capil- 
lary tube. If a compressible medium like air is used, dilatation of the 
cardia from a small caliber to the full size of the dilator can take place 



200 DISEASES OF THE DIGESTIVE TRACT 

without materially lowering the pressure, and therefore should the tis- 
sues begin to give way, a large rent in the esophagus might suddenly 
occur. To provide against further accidents, dilators of increasing size 
should be employed, but this is no safeguard unless sufficient pressure 
is used to give assurance that each successive size is extended to its 
full diameter. Two or three dilatations have been sufficient, as judged 
by the results obtained, to completely paralyze the circular musculature 
of the cardia. Recurrence of the dysphagia will depend largely upon 
the ability of the dilated esophagus to regain its normal size and tone. 
Relapses are to be expected in some of the cases. 



THE STOMACH 

Gastralgia 

Gastric pain may be caused by either one of two general patho- 
logical conditions. First, it may be caused by erosion and ulcera- 
tion of the mucous membrane over considerable surface of the 
stomach, thus exposing the sensory nerve endings. That is usually 
the accompaniment of hyperacidity. Second, it may be due to the 
distention of the viscus by gas. This is usually the accompaniment 
of an acidity or atony. In the first type the epigastrium is tender 
to pressure, in the second case it is sometimes tender and some- 
times not. 

If the pain be due to erosion or ulceration, the treatment dis- 
cussed under hyperacidity is indicated. 

If, on the other hand, it is due to the presence of gas, temporary 
relief may be obtained by causing this gas to pass off. Thus, hot 
drinks usually stimulate the pylorus to open and the consequent 
peristalsis then carries the gas through the intestine, or else causes 
belching, which brings the gas up through the mouth. Ginger 
and other stimulant stomachics have a like influence in starting 
up the peristalsis. If the pain, however, is quite severe, morphin 
may have to be resorted to to relieve the patient while the physi- 
cian proceeds with some causal treatment, such as gastric lavage. 
But in either case it may be profitable to the future well-being of 
the patient to have a thorough gastric lavage, which would clean 
off and revitalize the mucous membrane. Or, on the other hand, 
the use of mineral waters until the gastrointestinal tract is thor- 
oughly cleansed may be sufficient if gastric lavage be not feasible. 



THE STOMACH 201 

Where such gastric pain from gas distention is habitual, a carbon- 
ated alkaline water should be given regularly, preferably on an 
empty stomach, until the condition is relieved. For instance, in 
the morning at least half an hour before breakfast, and if neces- 
sary at a similar interval before the other meals also. If the 
trouble be a simple one where the mucous secretions of the stomach 
need merely some stimulation, a simple carbonated water is suf- 
ficient; but if the whole intestinal tract be relaxed, carbonated 
alkaline waters would be better. The quantity varies with the 
strength of the water. Usually it ranges between four and eight 
ounces. The waters should be sipped rather than gulped, and 
where the whole system seems relaxed and flaccid, hot rather than 
cold. 

Anacidity 

As will be noted, the above measures remove the results of the 
abnormality in the gastric secretion, that is, they constitute the 
symptomatic treatment. The causal treatment, on the other hand, 
is as follows : 

Whether functional or organic, anacidity is most satisfactorily 
treated by giving dilute hydrochloric acid 1 one half hour after 
meals. The dose should be 15 to 30 drops in plenty of water. The 
condition can be helped considerably by active bodily exercise in 
the open air, and also by massage and friction baths. 

It will frequently, however, be necessary to give the acid in 
some combination that will obviate the necessity of the patient's 
measuring out his own medicine by drops (as in charity and tene- 
ment house work). In that case, a prescription with the bitters 
would be useful, e. g. : 

^ Acidi hydrochlor. dil 15.0 c.c. 

Tinct. gentian, co 30.0 " 

Ext. fl. cascarae sag 8.0 " 

Glycerini 90.0 " 

Aquae destill 60.0 " 

M. D. S. : One dessertspoonful in water thirty minutes after 
eating. 

1 The officinal drug is a 10 per cent solution of the strong acid. The normal 
acidity of the gastric juice gives a test of total acidity between 40 and 65 mm. 
of decinormal sodium hydroxid solution. 



202 DISEASES OF THE DIGESTIVE TRACT 

Hyperacidity 

Fats, when given before other foods, have a tendency to check 
the secretion of the gastric juices, therefore the best treatment 
of hyperacidity is the use of olive or other oil in tablespoonful or 
larger doses just before meals. Where the oil is not palatable the 
following prescription may be used (Cohnheim) : 

1J Tct. belladonnas folior 5.0 c.c. 

Olei amygdalae dulcis 30.0 ' ' 

Vitelli ovi unius 

Aquas destill q. s. ad 200.0 " 

M. f. emulsio. D. S. : A tablespoonful t. i. d. just before eating. 

For the relief of pain, which usually occurs at the height of 
gastric digestion, bismuth subnitrate in 20-grain doses, or soda in 
1- to 2-grain doses, in water will be found efficient. 

Illustrative Case Histories (from Cohnheim 's text) : 

Case I. Frederick B., a tailor, thirty-one years old, had for two years 
suffered from pressure in the stomach after eating solids, and had an 
inclination to diarrhea. There had been an exacerbation of the symp- 
toms for two weeks, after he had eaten currants. Patient's appetite 
was poor, except for highly seasoned foods. He was emaciated and pale. 
He had catarrh of the apex of the right lung. The greater curvature 
of the stomach reached to the umbilicus. The microscope showed the 
test breakfast to be poorly digested. The total acidity was 20. 

Treatment. — Kissingen water, a diet of semisolids, and hydrochloric 
acid. Five weeks later pressure in the stomach had almost entirely dis- 
appeared, and patient was discharged. 

Case II. Mr. R., a merchant, twenty-seven years old, was a heavy 
smoker. The patient had suffered periodically for a year and a half 
from cramplike pains in the stomach, two or three hours after meals, 
which were always relieved by eating again. He had always had a 
hearty appetite. 

Treatment. — Half a wineglassful of olive oil was prescribed in the 
morning and a cup of milk of almonds at noon and in the evening 
before eating. Belladonna, combined with an alkali, was given twice 
daily after meals. The patient was immediately free from discomfort 
in the stomach. The after treatment consisted in the use of Vichy 
water. 



THE STOMACH 203 



Gastric Ulcer 

We have already made some mention of ulcer of the stomach in 
connection with onr study of the pathological conditions of mucous 
membranes, and we have seen that bismuth subnitrate, orthoform, 
and atropin represent the types of drugs to be used to quiet the 
pain and protect the abraded tissues. The condition demands ab- 
solute rest, both of the body in general and of the digestive func- 
tion in particular; therefore patients suffering from round ulcer 
of the stomach are, whenever it is possible, put to bed and given 
no food whatever by the mouth for perhaps a week. All nourish- 
ment during this time is given by the rectum in the form of nu- 
trient enemata. Peptonized milk and eggs are used for this pur- 
pose. To make these enemata most effective, the rectum should 
be cleansed with an enema of one to two pints of sodium bicarbon- 
ate solution one hour before the injection of the nutrient enema. 
After the rectum is emptied, the patient lying on his left side, the 
enema should be put in through a rectal tube, slowly, in order to 
avoid irritation which would cause it to be expelled before it has 
had time to be absorbed. The solutions used for nutrient enemata 
should be dilute in order to conform to the laws of endomosis. 
They should be as thoroughly predigested as possible in order that 
they may resemble the chyme that is absorbed from the upper 
intestinal tract. The agent for the predigestion is usually pan- 
creatin. Enough soda is added to the powdered pancreatin to 
make the solution alkaline, in order that it may afford the best 
conditions for the development of the ferment action. 1 The inter- 
val between two nutrient enemata is usually six hours. The typical 
composition of a nutrient enema (Boyd and Robertson ) is: Yolks 
of two eggs; 30.0 (1 ounce) pure dextrose; 0.5 (7 grains) common 
salt; pancreatized milk sufficient to make 300.0 (9 ounces). 

During the second week, feeding by mouth may be begun. The 
only food allowed at first is liquid, and this is given in two- to five- 
ounce doses every three hours. At first milk may be used diluted 
with a carbonated water, such as Vichy. Later, the fresh, undi- 
luted milk may be used; then milk with bread soups, tea with 



1 Pancreatinizing powder may be purchased ready for use. The two best 
known are Fairchild's and Wyeth's. 



204 DISEASES OF THE DIGESTIVE TRACT 

cream, cocoa cooked with cream; then oatmeal, rice, corn meal, or 
wheat gruel may be given for variety. Butter may be used freely. 
For such patients as can take them, raw eggs may be given in the 
first food by the mouth, instead of the milk; but because so many 
people are nauseated by the thought of taking raw eggs, the prac- 
tice cannot be made general. 

The next week something more substantial may be added, and 
so on, until finally after about six weeks the patient reaches a fairly 
normal diet — at least a diet that will maintain the normal equi- 
librium. 

The essential part of all these treatments is the rest in bed, and 
more failures probably result from the patient's getting up too 
soon than from any other one cause. The patient must avoid for 
several weeks coarse breads, fried potatoes, acids, pastries, cabbage, 
cheese, goose, duck, fat pork, ham, bacon, eel, salmon, legumes, etc. 

The bismuth and the orthoform are used in this course of treat- 
ment only when the pain renders some sedation necessary, as at 
first, before the rest has succeeded in quieting the gastric pain. 
The bismuth is used in doses of 1 gram (15 grains), suspended in 
water, and the orthoform similarly in a one-per-cent suspension. 

Another prescription to quiet pain, to be used after eating, is 
the following : 

^ Ext. belladonnas folior 0.2 

Magnesii oxidi 

Sodii bicarbonatis aa 25.0 

M. D. S. : One teaspoonful, one or two hours after food, two 
or three times a day. 

Still another combination of drugs suitable for relieving the 
pain of ulcer is the prescription from Cohnheim given above in 
our discussion of gastric hyperacidity. 

Cancer of the Stomach 

Cancer of the stomach is, of course, a surgical disease and 
should be treated by excision or exclusion whenever possible. 
Many cases of inoperable cancer will, however, be found in every 
man's practice, and these demand the most painstaking care. 

Many years ago, Professor Friedreich, of Heidelberg, thought 



THE STOMACH 205 

he had found in condurango bark a specific against cancer, because 
it seemed to stimulate the appetite of the patient and enable him 
to take food and for a short time often gain in weight. The drug 
has turned out, however, to be only another of the stimulant 
stomachics. Nevertheless, it is useful in cases of inoperable can- 
cer, when given in connection with the other indicated remedies. 

The first of these is arsenic. It is used for the sake of building 
up the body to greater resistance. It is sometimes injected directly 
into the tumor in the hope of securing thereby its caustic effect, 
but in case of cancer of the stomach this is, of course, impossible ; 
therefore it is given either by the mouth as Fowler's solution, or 
3*0 grain arsenious trioxid pills, or injected every other day in 
doses of 0.05 grams of arsacetin into the muscles of the back. 

The diet in cancer of the stomach should, of course, be such as 
to pass through the pylorus. When this is closed, nothing remains 
but rectal alimentation and the frequent use of gastric lavage. 
When, on the other hand, the pylorus is open, one can still feed 
by mouth by having recourse to predigested foods. Painstaking 
attention should be given the condition of the bowels and no con- 
stipation or clogging permitted. An illustrative prescription for 
use in such a case of gastric cancer would be : 

If Fl. ext. corticis condurango 2.0 

Fl. ext. cascaras sagradas 0.5 

Acidi hydrochlorici diluti 1.0 

Glycerini 5.0 

Essentia^ pepsini 5.0 

For one dose, to be given about thirty minutes after food. In 
this prescription, the cascara is used for its laxative effect, the 
hydrochloric acid to supply the lack of acidity always found in 
gastric cancer, and the glycerin and essence of pepsin form a 
synergistic vehicle. The taste of the medicine thus prepared is 
rather bitter, and for that reason patients should take it in water 
if the bitterness prove disagreeable. 

Pyloric Stenosis 

This is a surgical condition and comes to the physician only 
for diagnosis or when an operation is out of the question. Here 



206 DISEASES OP THE DIGESTIVE TRACT 

gastric lavage is absolutely necessary to keep the stomach free 
from fermenting food stuffs, and should be done at first twice a 
day, at morning and at night, until no detritus is found in the 
returning water. After the lavage, 50 to 100 c.c. of warm olive 
oil may be introduced into the stomach. This may be done 
through the tube, but preferably by drinking. There should be 
only two meals a day, and these should be fluid, but should contain 
as much of albumin and oil as possible, and in such condition as 
will most easily pass the pylorus. In benign stenosis the stomach 
can sometimes digest meats and albuminous foods when they are 
ground fine; but in malignant stenosis the gastric secretions are 
too weak to do this. 

The only drugs that should be used in this condition are anti- 
fermentatives and antiseptics to check the fermentation caused by 
the stagnation of the food in the stomach, and the antispasmodics 
to relax the pyloric sphincter as much as possible. Therefore we 
give the bismuth subnitrate as antifermentative and sedative, and 
belladonna as an antispasmodic. Sometimes the use of olive oil 
with the tube obviates the necessity of any other medication. On 
the other hand, we find cases requiring the use of papain and other 
digestants to assist in preparing the food for the duodenum. Pa- 
pain should be given in such a case in doses of 5 grains soon after 
eating. 

Portal Congestion 

Frequently dyspepsia is due to the congestion of the mucous 
membrane throughout the portal circulation. This causes a faulty 
secretion of the digestive juices and also a feeling of discomfort 
and weight. The taking up of so much blood in the splanchnic 
area leaves the extremities cold and the skin clammy and pale. The 
best treatment is a hygienic one wherein by massage and exercises 
these blood vessels are stimulated to contraction and the blood 
is driven into other parts of the body. Cold baths, the alternating 
hot and cold douche over the splanchnic area and over the back, 
combined with drugs that will stimulate the peristalsis, seem to be 
valuable in obtaining relief. The patient should have regular 
hours of sleep, as regular hours of eating, and should not attempt 
to rob the digestive tract of its due share of blood after meals 
through intense mental activity. 



THE STOMACH 207 

The drug treatment is chiefly by means of the stimulating sto- 
machics (bitters), varying according to the acidity of the stomach 
contents and the tone of the stomach wall. I use for such bitters 
chiefly the compound tincture of gentian, condurango, and berberis. 

Functional Gastric Disorders 

In functional gastric disorders, suggestive therapeutics com- 
bined with hygienic regulation of the life usually bring about a 
cure. The regulation of the diet must proceed on the principle of 
stimulating the stomach and proving to the patient the soundness 
of the organ. In general, forced feeding combined with a rest cure 
is the plan adopted. The drug most used for the stimulation of the 
stomach is valerian (or its derivative baldrian), which seems to 
have a desirable general as well as local effect. The tincture is 
often made the vehicle for other and stronger drugs. Thus, for a 
case of nervous atony with constipation, we might give the fol- 
lowing : 

^ Acidi hydrochlorici diluti 10.0 

Ext. fl. cascarae sagradse 6.0 

Tct. Valeriana? q. s. ad 100.0 

M. D. S. : One teaspoonful in water or milk one half hour after 
eating. 

Finally, we must remember that many gastric disorders are 
caused by troubles than can be removed, such as those of vision and 
mastication, as is most interestingly shown in the following case 
history from Harry Campbell's book of essays on treatment: 

A man, thirty-five years old, was a great sufferer from indigestion, 
and he had become pale, emaciated, nervous, and irritable. He went 
to the Continent and consulted several specialists there. They drew off 
the contents of the stomach at various intervals after each meal, and 
examined them chemically with a view to discovering the power of the 
stomach to digest different articles of diet; those which were not prop- 
erly digested were removed from the dietary, until finally the patient 
was restricted to three or four. The amount of fixed and free acids 
was also estimated, and special drugs were administered in order to 
correct certain defects that the calculation revealed. The result of this 
very scientific treatment was that the patient lost weight, and that he 
got more anemic, more irritable, and more nervous than ever. When 
15 



208 DISEASES OF THE DIGESTIVE TRACT 

I saw this patient he was a veritable skeleton. I found that he had 
astigmatism (he was a great reader), and that his teeth were not as 
good as they might be. These errors were at once corrected, and then, 
as he was in a very exhausted state, I had him put to bed and fed up. 
There was no need to be very particular about his diet, for from the 
very beginning he digested his food quite well now that the sources of 
irritation, in the eyes and teeth, were removed, and he was no longer 
scouring the Continent in search of doctors. 

Gastric Dilatation 

The dimensions of the stomach are not to be given exactly be- 
cause so mnch depends upon the tone of the musculature and the 
history of the individual. The vertical distance from the greater 
to the less curvature in the middle of the stomach is usually stated 
to be 9 to 11 centimeters. At least such is the ordinary distance 
beyond the cardia which the sound or stomach tube must pass 
before it reaches the lower wall. The capacity of the stomach has 
been stated by different authors, as follows : 

Ewald 250 c.c. to 1,680 

Luschka 1,500 c.c. to 2,000 

Schuren 2,430 c.c. 

Vierordt 2,980 c.c. 

Beneke 3,800 c.c. 

Brinton 3,130 c.c. 

Soemmering 2,500 c.c. to 5,500 

Henle 2,500 c.c. to 5,500 

Ost 2,533 c.c. to 2,700 

These figures have been gathered for the most part from cadavers, 
and are therefore too high. At any rate, we would have to say 
that anything above 2,500 c.c. is abnormal, and that therefore the 
normal capacity of the stomach should not exceed 1^ to 2 liters. 
For instance, the stomach that at the post-mortem examination 
held 3,060 c.c. of water, during life reached almost to the sym- 
physis and therefore belonged to the worst degree of dilatation. 

At the present time we understand the expression " dilatation of the 
stomach " to mean that form of gastric disturbance in which the stomach 
is unable to empty itself of its contents, with a resulting persistent stag- 
nation of food. The location of the greater curvature is in itself irrel- 



THE STOMACH 



209 



evant in the diagnosis of dilatation of the stomach. The question is not 
as to the size of the stomach, but only as to its motor function. 

The term " gastrectasis " originated at a time when physicians had 
not learned to recognize the initial stage of the affection, but only its 
final stage — dilatation of the organ — and this was considered the most 
significant symptom of the disease. When we use the expression " dila- 
tation of the stomach," therefore, we must from the outset be clear 
that we mean only the symptom of an actual disease rather than a dis- 
ease per se. To make the condition quite clear, a comparison of the 
stomach with the heart is very applicable, for just as acute dilatation of 
the ventricles of the heart may arise from valvular insufficiency, so acute 
dilatation of the stomach may occur from overloading the organ, as a 
result of errors in diet, or from paralysis of the nerve-muscular apparatus. 

On the other hand, chronic dilatation of the stomach is without 
exception the result of an ob- 
struction at the pylorus or du- 
odenum, just as hypertrophy and 
dilatation of the ventricle re- 
sults from valvular affections. 
Hence the primary factor is al- 
ways an obstruction which causes 
stagnation of the food, this in 
turn producing dilatation of the 
stomach. 

Every dilatation of the stom- 
ach is therefore a vitium py- 
lori or duodeni (obstruction) 
in the stage of disturbed com- 
pensation. 

As has already been men- 
tioned, it is necessary to differen- 
tiate between acute and chronic 
forms of motor insufficiency of 
the stomach. Acute dilatation is 
extremely rare, and in general 
corresponds to acute gastritis 
after indigestion or to ileus 
which is located high up in the 
intestine. (Cohnheim.) 




Fig. 33. 



-poche sous-pylorique of 
Chapotot. 



The result of gastric dilatation and gastrectasis is to be seen in 
the accompanying illustration following Chapotot, showing the 



210 



DISEASES OF THE DIGESTIVE TRACT 



pocket which is below the level of the pylorus, and therefore not 
to be emptied in the usual manner. 



Gastric Lavage 

The use of the gastric sound reaches back into the time of Greek 
antiquity, but was not brought into prominence until in the time 
of the Roman emperors, when their banquets demanded the fre- 
quent emptying of the stomach in order that the banqueters might 
take more food. The means for emptying the stomach were first 
the sticking of the finger into the throat to cause vomiting. The 
finger was succeeded by the use of a feather, and this in turn 
by a glove finger, the lower two thirds of which were filled out 
by wool and the upper third left empty 
for the insertion of the physician's finger. 
This in turn was succeeded by the lorum 
vomitorum, which, on account of its fearful 
taste, produced the desired effect. This was 
a sound doctored with 
vile-tasting compounds, 
which when put into 
the throat immediately 
caused vomiting. In 
the second half of the 
seventeenth century 
there was developed the 
stomach brush, which 
consisted of a long 
pliable fish bone, on 
the lower end of which 
were fastened pieces of 
linen or silk, or even 
wire, for scraping out 
the inside of the stom- 
ach. Then a regular 
brush was used, but 
since this sometimes 
brought on hemorrhage or asthmatic attacks, it was soon laid 
aside. 




Fig. 34. — Original Method of Gastric Lavage 
Without the Help of a Physician. 



THE STOMACH 



211 



In 1716 Fabricus ab Aquapendente invented his silver canula 
for inserting into the nose of patients suffering from lockjaw. 
This was improved upon by John Hunter, who used a hollow bou- 
gie or catheter. Along in the beginning of the nineteenth century, 
Bush and Juke performed gastric lavage by means of a syringe 
and rubber tubes, but it was not until 1870 or later that the soft 
rubber tube was introduced into England, from which it spread 
to different parts of the world. 

Scientific gastric lavage was developed by Kussmaul in 1867. 
The instruments, however, had been developed at different places 
and different times, and were simply brought into systematic and 
logical use by Kussmaul. At first a pump was used for emptying 
the stomach of its contents, and this was succeeded by the use 
of the siphon. The ac- 
companying illustration, 
taken from a publication 
in the early part of the 
'70s, shows the method 
used at the Jena clinic 
under Gerhardt for pa- 
tients who were able to 
pass the tube themselves. 
We now use improve- 
ments on this method, 
but the same principle. 

Of stomach tubes 
there are on the market 
practically two types, as 
shown in the accom- 
panying illustrations. 
The one depends upon 
the siphon principle, the 
other (Ewald's) upon 
the suction exerted by 

the rubber bulb to remove the stomach contents. These tubes are 
marked by a ring at the point which should be between the teeth 
when the end has reached the stomach. 

The caliber of the tube should be governed by the diameter of 
the narrowest point in the esophagus — the point opposite the cri- 




Fig. 35. — Ordinary Type of Stomach Tube With 
Funnel and Bulb. 



212 



DISEASES OF THE DIGESTIVE TRACT 



coid cartilage. This varies considerably. Thus von Hacker found 
it to be 16 mm., Mackenzie 19J, both measures being from large- 
sized adults. Manton, however, found a diameter of 14 mm. ; 
hence it is unwise to use a tube over 13 mm. in diameter. 

The passage of the tube by the cricoid with its projecting ring 
is accomplished best by having the patient swallow. This draws 

the cartilage forward, 
away from the verte- 
bras. When this does not 
succeed, we can push the 
larynx forward by in- 
serting the forefinger, as 
shown in the accom- 
panying illustration. 

The length of the 
esophagus is given by 
various authors thus: 
Krause, 21.6 to 24.4 cm. ; 
Luschka, 28 cm. ; Laim- 
er, 25 to 26 cm. ; Moro- 
sow, 24.5 to 25 ; Sappey, 
22 to 25.5. Rosenheim, 
on the other hand, says 
it is T 5 g- of the length of 
the trunk. 

The distance of the 
front teeth to the upper 
end of the esophagus is usually 14 to 15 cm., hence the mark on the 
stomach tube, to show the point that should rest between the teeth, 
should be the sum of the two lengths; that is, 40 to 42 cm. from 
the lower end. 

One can estimate on the patient approximately the distance 
from the incisors to the cardia by using Kussmaul's method. This 
is to pass the sound or tube from the mouth along the cheek, un- 
der the ear, and down the back to the height of the tenth thoracic 
vertebra, for this represents the level of the cardia. The begin- 
ning of the esophagus is similarly represented by the level of the 
sixth cervical vertebra. 

Gastric lavage should be used whenever there is pyloric 




Fig. 36. 



-Pulling the Larynx Forward Before 
Inserting the Tube. 



THE STOMACH 213 

stenosis, or gastric fermentation, or mucous gastritis, and also 
after the ingestion of poisons. It is of great value in cases 
of gastric neurosis, atony, etc., being useful even in many 
cases of gastric erosion and ulcer. In case of carcinoma ven- 
triculi it can be used, but only with, great caution, lest the tube 
perforate the wall. It is contraindicated in case of aortic aneu- 
rysm on account of the danger of rupturing the weak vessel 
walls. 

The tubes should be of soft rubber and have an opening on the 
side as well as at the end. 

To insert the tube with the patient sitting in an ordinary chair, 
one should stand behind and to his right. The patient's head 
should rest against the operator's left chest, with the operator's 
left arm encircling the head and his left hand supporting the tube 
at the patient's lips. With his right hand the operator then pushes 
forward the tube to the uvula, and as the patient swallows, pushes 
it gently forward into the esophagus. The tube is then carried 
downward by successive swallowing movements until it reaches the 
stomach. 

Should this method not succeed, the operator may stand in 
front of the patient and insert his left forefinger and press for- 
ward the larynx and then pass the tube by the side of his forefinger 
with his right hand. 

The tube should be moistened thoroughly in cold water or 
glycerin before being introduced. 

As soon as the stomach is reached the funnel end of the tube 
should be lowered over a basin and the patient asked to press as 
at stool. This usually brings up some of the gastric contents. 
This part is usually set aside for laboratory examination, and then 
the real lavage begun. For this the funnel is raised to the height 
of the patient's head and the solution poured slowly into the tube. 
The air in the tube may cause some difficulty at first, but this may 
usually be overcome by raising the funnel until the tube is nearly 
vertical. Because of the blockade cause by air and its unpleasant 
effects when forced into the stomach, care should be taken to pour 
the solution in a steady stream until the quantity desired has 
reached the stomach. When sufficient quantity has been poured 
in, the funnel should be quickly lowered (with the water still in 
it to start the siphon action) over the basin to empty it out again. 



214 DISEASES OF THE DIGESTIVE TRACT 

The process of filling and emptying should be repeated until the 
water returns clear. 

As to the quantity of solution to be used for each filling, few 
figures generally applicable can be given, for everything depends 




Fig. 37. — Stomach Washing, when it is Necessary to Pull Forward the 

Tongue (Caille). 

upon the irritability of the stomach. In general, one should use 
enough to dilate the organ somewhat, but not enough to give dis- 
tress. Frequently the patient will vomit up the solution outside the 
tube as soon as the stomach is nearly full. This, of course, is un- 
pleasant, but does no damage. It gives a limit for the next filling. 

Before passing the tube the patient should be warned of the 
feeling of suffocation and told that there is no danger, and that 
he has only to take long, forced respirations to overcome this dis- 
comfort. 

Of solutions to be used simple warm water is best for all general 



THE STOMACH 215 

purposes. When the presence of microorganisms has been demon- 
strated in the stomach salicylic acid in the strength of one fourth 
per cent may be used. When morphin has been ingested potassium 
permanganate in 1 : 1,000 to 1 : 4,000 dilution may be used in order 
to oxidize the morphin still within the stomach. When the stomach 
is coated with mucus warm alkaline mineral waters (Waconda, 
White Rock, Congress, Sulpho-Saline) should be used. 

In general, it is best to use the tube either early in the morning 
or late in the evening. In cases of fermentation, the evening hour 
is better because it insures a good night's rest. When a mucous 
gastritis is present the morning hour is better, in order to free the 
stomach of mucus preliminary to the ingestion of food. Once a 
day seems sufficient for most cases. 

In chronic cases patients should be taught to use the tube 
themselves. Then they may either use the ordinary tube and have 
some one help them to pour the water and place the basins, or they 
may secure an apparatus like that shown in the accompanying il- 
lustration and perform the lavage alone. 

Whenever the holes in the tube become blocked with food par- 
ticles it is usually better to withdraw the tube, cleanse it, and re- 




Fig. 38.— The Ewald Tube (Shortened). 

insert it than to try to dislodge them by pouring in extra water or 
similar maneuvers. In withdrawing the tube one should compress 
it between the thumb and finger (as one does a catheter), so that 
none of the contents can escape until it is safely in the basin. One 
should also withdraw it very quickly; usually one single pull is 
sufficient. 



216 



DISEASES OF THE DIGESTIVE TRACT 



Needless to say, the patient should rest after the treatment. 

The tube should be cleansed out in hot water immediately and 
then hung up to drain. It should not be boiled. 

To use the Ewald tube, we pass the tube separated from the 
bulb, and then attach the latter compressed. Its expansion sucks 
the stomach contents upward into it. If it becomes filled, it should 
be detached, emptied into sterile glass vessel (if the contents are 
to be examined), and reattached compressed. Lavage with this in- 
strument is very slow, because one can put in so little fluid without 
refilling the bulb. 






39. — Esophageal Stricture. An obstacle to the passage of the 
stomach tube. 



The presence of esophageal diverticula may cause some diffi- 
culty in passing the stomach tube, as is indicated in the illustration 
from Gumprecht on this page. In such cases the measurement of 
the height at which the obstruction is met should next be under- 
taken, to make sure that it is within the limits of the esophagus. 



THE LIVER 

Although the diseases of the liver are usually considered among 
those of the gastrointestinal tract, nevertheless they differ in their 
pathology from other intestinal diseases, because the liver is essen- 
tially a separate gland, and therefore influenced by, and influen- 



THE LIVER 217 

cing, in a more involved and obscure way, the general systemic 
metabolic processes. The liver, for instance, acts as a filter to 
separate out the poisonous products of intestinal digestion, as well 
as the waste products of metabolism. It also provides the bile 
which influences intestinal digestion; hence, whenever the organ 
does not do its work properly, or is inflamed, we have not only 
the local discomfort and interference with digestion, but we have 
also the direct poisoning of the body from the absorption of the 
by-products of digestion. Among these systemic effects we find 
mental and nervous depression, changes in the blood, and brady- 
cardia. Whether these changes are caused by the absorption of 
the coloring matter of the bile, or of the bile salts, or of the pep- 
tones, is immaterial to this issue, because the general process is 
the same. Only when we come to a discussion of antidotes for this 
toxemia does it become necessary to know which product of the 
liver's activity (or lack of it) we must neutralize. 

Icterus 

The most common symptom of liver disorder is icterus, or jaun- 
dice. That it is a symptom and not a disease entity is very im- 
portant for us to realize in order that we may not seek to treat the 
jaundice for itself, but may institute the proper investigations to 
establish the causation of the symptom and thus diagnosticate the 
real lesion. Icterus (that is, the discoloration of the skin and 
mucous membranes) is, of course, due to the absorption of bile by 
the blood and the deposit of the coloring matter along the capil- 
laries. Usually such absorption occurs only when an obstruction 
of some sort prevents the flow of bile into the duodenum. Some- 
times, however, toxic processes may be at work, causing the ab- 
normal absorption of bile by the blood. Cases of the latter type 
are, fortunately, rare, for they indicate a condition upon which 
bur therapy has little effect. Of the causes of obstruction, the most 
common is the lodgment of gallstones in the common duct. Then 
follow inflammation of the biliary passages, inflammation of the 
duodenum in and about the outlet of the common duct (so as to 
block the outlet), and tumors large enough to compress the ducts. 
(This compression of the ducts is also increased by tight dress- 
bands and corsets.) 



218 DISEASES OF THE DIGESTIVE TRACT 

Fortunately the skin usually begins to regain its normal color 
as soon as the obstruction is removed. Only after repeated attacks 
do we find a permanent discoloration of the skin or the develop- 
ment of xanthoma; therefore we do not need ordinarily to combat 
the coloring process or seek agents to decolorize the tissues. 

Hence the treatment of icterus is the treatment of the under- 
lying cause ; but, on the other hand, we often must seek some relief 
for the symptoms caused by the toxic constituents of the bile, 
such as the tendency to capillary hemorrhage, the vomiting, the 
itching, the sleepiness, and the other nervous symptoms. For in- 
stance, for the tendency to capillary hemorrhage we may use cal- 
cium salts (although late researches indicate that they do not 
affect the coagulability of the blood), stypticin (cotarnin hydro- 
chloride adrenalin (intravenously), etc. The favorite calcium 
salt is the lactate, because of its lack of irritation. This may be 
given in fifteen-grain doses as frequently as desired. Ordinarily, 
the interval varies from two to four hours. This raises the calcium 
content of the blood and neutralizes the bile acids or coloring mat- 
ters which seem to be paralyzing the vasomotor tone of the smaller 
blood vessels. Stypticin may be given in doses of three fourths of a 
grain every three hours (if the stomach will retain it) . The maximal 
daily quantity is nine grains. Its effect is still more problematic 
than that of the lime salts. Adrenalin chlorid may be introduced 
(slowly, drop by drop) into a vein in doses of ten to even twenty- 
five drops. The effect is, temporarily, at least, good, in that the 
blood pressure is raised and the vasomotor centers stimulated. 
Thyroid extract, three grains three times a day, given with calcium 
lactate, twenty grains three times a day, has caused the coagulation 
time to fall in a case of gallstone disease from eight to two and a 
half minutes within a few days, and therefore seems, for the pres- 
ent at least, the most promising therapy for the tendency to capil- 
lary hemorrhage. 

The pruritus is best treated by sweat baths. Of such baths the 
hot-air cabinet yields results the most pleasantly and quickly. The 
patient should be wrapped loosely from the neck down in three or 
four layers of cotton blankets or Turkish toweling and kept in the 
cabinet with a temperature of 225 to 275° F. for thirty to forty- 
five minutes. Ice-water cloths should be kept on the forehead and 
the pulse and respiration carefully watched. Should the pulse run 



THE LIVER 



219 



to 120 per minute, the heat should be turned off at once. At the 
close of the bath the patient should be sponged off in warm water 
and put to bed. The purpose of these baths is to remove from the 
skin and its glands the irritant matters causing the itching. The 
general effect of these sweat baths is also good in that it helps 




Fig. 40. — Electbic Bath Cabinet Room, Illinois Westebn Hospital for the 
Insane, Watertown, Illinois. 

eliminate the toxic matters from the body and stimulates the slug- 
gish metabolism. 

The depression of the nervous system calls for the stimulation 
of the emunctories — skin, kidneys, and bowels. The use of cam- 
phor (ten-per-cent solution in a sterile neutral oil) subcutaneously 
in doses of 6 c.c. pro die may give symptomatic relief. But the 
use of hot baths, mineral waters, and diuretin (the latter in doses 
of one half to one gram t. i. d.) are attended with more permanent 
effect. We may substitute, but with less effect, electric-light baths, 
hot-tub baths, and steam baths, given in sufficient strength to cause 
free perspiration. 

Summarizing now our drug treatment, we have the following: 
We treat primarily the lesion causing the jaundice, as outlined in 
the following pages. The jaundice itself we treat chiefly by stimu- 
lating the elimination of the bile. Thus in uncomplicated cases we 
might prescribe (in addition to the physical therapy) the fol- 
lowing: 



220 DISEASES OF THE DIGESTIVE TRACT 

t 

IJ Diuretin 0.5 gram. 

Calomel 0.03 " 

M. f. chart, no. I. Da tales doses no. X. Sig. One powder 
three times a day. 

Should we need to stimulate the skin elimination by drugs, we 
give pilocarpin hydrochlorid subcutaneously in doses varying from 
■fa to J grain. This drug should be given only by the physician 
himself and repeated only as needed (usually twice a day), be- 
cause of its depression of the heart. The maximum daily dose is 
f grain (0.04). 

Should we discover the need of stimulating the whole body as 
well as the digestion, we might prescribe the following mixture: 

Tji, Tct. nucis vomicae 10.0 c.c. 

Magnes. sulphatis 30.0 grams. 

Diuretini 10.0 " 

Elixir simplicis 90.0 c.c. 

M. D. Sig. One teaspoonful in four ounces of water three times 
a day. 

The diet and the general conduct of the case must be governed 
by our diagnosis of the causative disorder. 

Of the diseases of the liver, some are beyond our power to af- 
fect, therefore we need spend little time in the consideration of 
such conditions as acute yellow atrophy, malignant neoplasms, 
amyloid, and fatty degenerations. On the other hand, we need to 
study thoroughly the treatment of gallstones, biliary inflamma- 
tions, and other remediable conditions leading to the disturbance 
of the liver functions. 

Hepatitis 

Cases of primary general inflammation of the liver are rare; 
more often we find an inflammation of the bile passages and the 
extension from them into the liver substance of the inflammatory 
process. 

The treatment for such conditions calls for the general unload- 
ing of the gut — and the stimulation of the excretion through skin 
and kidney also — and the physiological rest of the liver by giving 



THE LIVER 221 

foods making little or no demand upon the hepatic function. To 
attack the causes of the condition, the best we can do is to give 
by the mouth drugs that will disinfect the hepatic passages (as 
far as that can be done by drugs) and increase the flow of fluid 
through the secreting cells. We need also to furnish to the in- 
testine the product of which it is deprived by the disorder of the 
liver functions, hence a prescription for hepatitis would be illus- 
trated by the following: 

J^ Phenylis salicylatis 0.2 gram. 

Fellis bovis inspissatae 0.2 " 

Hydrargyri chloridi mitis 0.01 ' ' 

M. f. caps, gelat. no. I. Da tales doses no. X. Sig. One 
capsule every three hours. 

In place of the salol one might use hexamethylenamin in the 
same dosage, since both of these drugs have antiseptic properties 
while circulating in the body fluids. 

The diet must be liquid and yet albuminoid in character. Thus 
vegetable soups, predigested milk, custards, eggnogs, etc., given 
every three hours, illustrate the general prescription. The reasons 
for these requirements are that the presence of albumen seems to 
prevent the precipitation of bilirubin and the formation of gall- 
stones (Robson). The liquid food creates less disturbance and is 
more easily digested than the solid foods. The frequency of the 
meals tends to stimulate the formation of bile, or at least its dis- 
charge into the duodenum. 

The patient should be kept in bed in order to limit the combus- 
tion of tissue and the consequent labor of the liver. 

Synergistic with the bed rest is the stimulation of the emunc- 
tories. Hot baths, diuretics, and laxatives should be used care- 
fully, yet adequately. In general, calomel is the best cathartic in 
this condition, because its action is antiseptic as well as cathartic. 
It is best given in small and frequent doses, rarely exceeding two 
grains for the total daily dose. 

Inflammation of the Biliary Passages 

In this condition we find faulty secretion of the bile, the pres- 
ence of detritus, and microorganisms in the ducts, and consider- 



222 DISEASES OF THE DIGESTIVE TRACT 

able congestion of the mucous membranes. The stimulation of the 
circulation (active hyperemia) through the liver and biliary 
passages is therefore the first indication. This can best be brought 
about by deep massage, by the local application of hot and cold 
water (fomentations or sprays) in alternation, and the use of 
the thermophore. 

The food and drink of the patient should be regulated so that 
there is no stagnation in the duodenum. This means that the food 
should be nutritious, but not so bland that it would not stimulate 
the peristalsis, and that the meals should not be large. For exam- 
ple, a semisolid diet of eggs, milk, broths, scraped steak, etc., proves 
effective in most cases. Fresh grapes and other fruits can usually 
be given in addition. Mineral waters or other cathartics should be 
used to keep the peristalsis active. Of the mineral waters, the 
group known as alkaline cathartics (see list of waters) are best 
adapted to this class of cases. This water should be taken on an 
empty stomach, and where the patient is debilitated, as hot as can 
be well borne. Usually a wineglassful one half to one hour before 
breakfast, and another in the middle of the afternoon, will prove 
sufficient. 

Of the other cathartics, calomel in daily doses of one grain has 
proven of most worth. 

The old-time list of cholagogues has gradually been decreased, 
until now the only accepted cholagogue is bile. The apparent 
cholagogic effect of calomel is probably simply due to its inhibition 
of fermentation in the intestine, thus preventing the breaking up 
of bile in the intestine. 

As far as drugs needed to treat the local inflammation are con- 
cerned, the most useful are ox gall, to stimulate the flow of the bile ; 
salol or hexamethylenamin, to sterilize the biliary passages; and 
pancreatin, to assist in the digestion of the food in the duodenum. 

Ox gall is to be given in doses of 2 to 5 grains (0.1 to 0.3) sev- 
eral times a day, salol in doses of at least J gram (5 to 7 grains) 
three times a day. It should be remembered that the bile salts, 
when given in large quantities and absorbed into the system, pro- 
duce a digitalis effect on the heart. If the ox gall and pancreatin 
be confined in a salol-covered capsule or pill and this given about 
two hours after meals, probably the best results are obtained. A 
prescription illustrating this arrangement would be: 



THE LIVER 223 

^ Pancreatin 0.1 gram. 

Ox gall 0.3 " 

Calomel 0.01 " 

Make one keratin-covered capsule. Dispense twenty such pills. 

One group of men of merit is enthusiastic in recommending sodium 
succinate 1 in a dose of 5 grains every three hours for several 
months as an efficient treatment of chronic inflammation of the 
gall ducts and bladder. Whether or not such a treatment is ef- 
ficient, I am as yet unable to say. 

Another group of men is using a pill of the following com- 
position : 

I£ Acid sodium oleate 1J gr. 

Sodium salicylate If " 

Phenolphthalein ^ " 

Menthol T V " 

Sodium oleate 2 (that is, soap) probably has a similar influence 
to the sodium succinate in the above medication and works toward 
fluidizing the contents of the biliary tract. The sodium salicylate 
acts as an antiseptic, the phenolphthalein acts as a cathartic, 
while the menthol has a stimulant and analgesic effect upon the 
sffomach. 

1 Succinates. These belong to the oxalate series, but are practically nontoxic. 
They are slowly absorbed from the intestine and entirely broken up in the sys- 
tem. Whether or not, after being absorbed, they have a valuable influence on 
the biliary tracts is as yet unproven. The dose is (0.3) 5 grains every three 
hours, continued for weeks and months. 

2 Sodium oleate. This should not be confused with the officinal oleates, 
about which S oilman has the following to say: 

" Oleata. Solutions of bases (metallic or alkaloidal) in oleic acid. They are 
not definite chemic compounds, as the name would imply. The rationale of their 
use is that a substance is not absorbed by skin from aqueous, but from oily, 
solutions. Many substances, again, are not soluble in oils, but dissolve in oleic 
acid. The oleates therefore constitute a useful class of preparations when it is 
desired to secure the absorption of a drug through the skin. Many are diluted 
with olive oil. Five are officinal — four being oleates of alkaloids, the fifth of 
mercury." The claim is now made that this soap, sodium oleate, is one of the 
normal products of the mucosa of the biliary tract, and that this justifies its use 
in inflammations of the gall ducts. 
16 



224 DISEASES OF THE DIGESTIVE TRACT 

A variation of the above prescription is the following, which 
sells nnder the name of probilin : 

^ Acid, salicylic 0.02 

Natr. olein 0.08 

Natr. stear 0.04 

Phenolphthalein 0.01 

Camph. menth 0.03 

Excipien. q. s. ad pill no. I. Sig. Three or four pills several 
times a day. 

The use of hot fomentations over the liver region will help to 
overcome the pain and stimulate the local circulation. When 
jaundice is present, the use of a general hot bath is to be pre- 
ferred. 

Massage of the abdomen, when carefully supervised, is helpful. 
This should include the kneading and rolling movements. These 
treatments should not be prolonged enough to exhaust the patient, 
nor so vigorous as to cause pain; hence a prescription for two 
treatments daily, each lasting ten minutes, is usually sufficient. 

The patient should be kept in bed, or at least on a couch, for 
the reason given above. He should be encouraged to drink water 
between meals up to ten or more glasses a day. 

When such treatment does not succeed within a few weeks, #t 
is usually justifiable to perform a laparotomy and drain the in- 
flamed ducts or bladder. 

Chronic Cholecystitis 

When such biliary inflammations become chronic, they center 
in the gall bladder and we have the series of indefinite and puz- 
zling symptoms belonging to this disease. Thus there are epigas- 
tric pain, flatulence, irregularity of bowel action, headaches, at- 
tacks of vomiting, etc., symptoms that might be caused by several 
different lesions. The diagnosis once reached, an attempt at 
medicinal treatment should be made, but should this prove inef- 
fective, the patient should promptly be turned over to the surgeon. 

The treatment is essentially that outlined above, except that 
the use of large amounts of water need be emphasized. The sys- 
temic treatment by hydrotherapy and massage is usually essential 



THE LIVER 225 

to a cure, hence such patients find it most profitable to enter a 
sanatorium, where the diet may be regulated and mechanical and 
physical treatments thoroughly given. 

Gallstones 

Gallstones are usually due to the stagnation of the bile in the 
gall bladder. The stimulus to calculus formation is usually bac- 
terial infection, a condition that frequently accompanies stagna- 
tion. Of bacteria, the bacterium coli commune is the most com- 
mon, and the bacillus typhosus somewhat less frequent but more 
virulent. The process is probably somewhat as follows: Bilirubin 
is precipitated by a biliary inflammation as a bilirubinate of lime ; 
about this as a nucleus layers of cholesterin are formed until 
either the chemical conditions change or the stones become so large 
that they rub on each other and thus prevent further growth. 
Probably contributing causes are long intervals between meals, 
sedentary life, and portal congestion induced by the lack of 
exercise and the lack of deep breathing, which usually accom- 
panies it. 

Gallstones often give no symptoms of their presence until they 
are forced into the ducts. There, of course, they produce intense 
pain (biliary colic), and also, if in the common duct, jaundice. In 
case of such a colic, the pulse is small, the face is pale and pinched, 
the skin cool, and the forehead bathed in perspiration. The pain 
may be sufficient to cause syncope. Chills may occur and the tem- 
perature rise to 102° or 103° F. This, however, usually indicates 
the presence of an additional cholecystitis. As soon as the stone 
has passed into the intestine, the attack ceases and the patient 
feels as well as ever. 

The indications for treatment are the relief of pain and the 
dilation of the passages. The first calls for morphin in full doses 
and the second for atropin and heat, hence the subcutaneous in- 
jection of \ grain of morphin sulphate and -^ grain of atropin 
sulphate is the first procedure after the diagnosis is clear. Then 
the heat should be applied locally and hot water in large quan- 
tities given by the mouth. The latter does good even if the patient 
vomit it up immediately. In such case, some more should be 
drunk as soon as the patient can do so. Sometimes it is necessary 



226 DISEASES OF THE DIGESTIVE TRACT 

to anesthetize the patient with chloroform during such an attack, 
so great is the distress. 

During the interval the patient should be treated as for inflam- 
mation of the biliary passages. Should a second or third attack 
occur, he should be referred to a surgeon for drainage of the gall 
bladder. 

The use of olive oil to dissolve the stones is fallacious. On the 
other hand, it is a very good laxative and the soaps formed from 
it may be of use in stimulating the flow of bile in the ducts. It 
should be given after meals, unless the patient is suffering from 
gastric hyperacidity. (In the latter case, it should be given as 
directed in the discussion under that head.) Mineral waters are, 
of course, valuable, and patients suffering from cholelithiasis are 
often very much benefited by a stay of a few weeks at some springs. 
While there they should take plenty of the lighter waters rather 
than smaller quantities of the heavier ones. 

Hepatic Gummata 

Hepatic gummata and other conditions due to tertiary syphilis 
should be treated by a vigorous administration of the iodids, par- 
ticularly of the potassium iodid, using from 20 to 60 grains 
three or more times a day, in addition to the general treatment 
for the obstruction and other symptoms as outlined above. Such 
conditions seem to yield more quickly if mercury be given simul- 
taneously, as, for instance, intramuscularly in the form of the suc- 
cinimid (-£■ grain on alternate days deep into the glutei). 

Cirrhosis 

This condition is practically hopeless of restituo ad integrum; 
but, on the other hand, the patient can be made more comfortable 
than he would be without treatment. The whole life of the pa- 
tient should be regulated so that there be as little call made upon 
the liver functions as possible and drugs given to relieve the vari- 
ous symptoms of the disease as they arise. Thus if the patient 
lead a quiet life, spending a great deal of time outdoors (for 
instance, on horseback or driving), eat small meals of nutritious 
food, with very little of alcoholic stimulants or tobacco, the disease 



THE LIVER 227 

may of itself cease to progress and cause very little trouble for 
months or years. 

The chief complication in these cases is the portal congestion, 
with the consequent dyspepsia. This needs to be handled along 
the lines mentioned in discussing stomach troubles, but with the 
addition of mineral waters, which through their active irrigation 
of the stomach and upper bowel tend to keep the mucous mem- 
branes in much better condition. The vomiting may be restrained 
somewhat by the use of dilute hydrochloric acid, and the edema 
may be controlled by the use of diuretics, such as diuretin x and 
calomel, or by means of hot-air baths, or by the use of pilocarpin 
(hypodermically in J-grain doses). 

The diet may be, at first, at least, exclusively of milk ; but usu- 
ally buttermilk, thin oatmeal gruel, or thickened milk soups, and 
jellies may be added. Vegetables and fruits, when well cooked, 
may be added for relishes. Animal food should be forbidden ex- 
cept at rare intervals. No alcoholic or other stimulant should be 
permitted. 

Considerable attention should be paid to the clothing and 
every precaution taken against chilling the body and deranging 
the circulation. Such chilling also puts an extra load on the kid- 
neys, and this in turn affects the liver. 

Hence in cases of cirrhosis well-to-do patients can with profit 
move to some equable climate such as California or that along the 
Mediterranean coasts. 

The ascites accompanying liver cirrhosis may require mechan- 
ical removal (i.e., paracentesis abdominis). For this the patient 
is braced up in bed, and after cleansing the hypogastrium with 
soap and water and alcohol, a small trocar is thrust into the peri- 
toneal sac in the median line between the navel and pubic arch ; 
or, if the patient lie somewhat on one side, then into the more de- 
pendent side at about the same level. The place for the puncture 
is selected by its dullness on percussion, and since the intestines 
tend to float on top of the fluid, selecting a dull point on the de- 

1 For example, the following prescription may be employed : 

1^ Diuretin 0.5 gram. 

Calomel 0. 01 " 

M. f. chart, amylac. no. 1. Da tales doses no. x. Sig. One powder t. i.d. 



228 DISEASES OF THE DIGESTIVE TRACT 

pendent side usually keeps us clear of harming the bowel. The 
trocar is, of course, sterilized before using. The fluid should be 
collected in a clean basin and carefully measured. 




Fig. 41. — Manner of Holding Trocar. 

Should the patient feel faint, stimulants should be adminis- 
tered, such as aromatic spirits of ammonia and strychnin. If the 
fluid flow slowly, all may be removed that will come. 

In chronic peritonitis, some good seems to result from the fre- 
quent removal of the fluid, but in hepatic cirrhosis the only value 
of the operation is the relief from pressure symptoms. In fact, 
the drainage of the body fluids caused by the refilling of the peri- 
toneal sac has in some cases seemed to weaken the patient very 
perceptibly. 

The reinjection subcutaneously of this fluid in 3-c.c. doses has 
been advocated by Audibert and Monges in La Presse medicate for 
February 2, 1910. This should be accompanied by a chlorid-poor 
diet. (See Nephritis.) 

Abscesses op the Liver 

Liver abscesses call for operative treatment, the best of which 
is to open and drain ; hence in cases of chills and rigors due to the 
presence of solitary abscesses one should not waste time with drugs, 
but should call upon a surgeon to evacuate the pus. 

Hydatid Cysts 

Hydatid cysts may be aspirated and part of the fluid with- 
drawn. This would serve to fix the diagnosis even if it did not 
kill the embryo (which, however, it usually does). But probably 



THE INTESTINES 229 

the best method is to have a surgeon do a laparotomy and clean 
out the cyst radically under the guidance of his eye. 

THE INTESTINES 

Enteralgia 

Enteralgia, or colic, is a symptom of various gastro-intestinal 
disorders and should lead us to seek out the lesion, and never per- 
mit us to content ourselves with relieving the pain. It may be 
due to irritation of the nerve ends in the intestine or reflexly to the 
irritation coming from other centers or from disorders of the nerve 
trunks themselves. Thus colic may be brought on by the irritant ac- 
tion of hard masses in the intestine, such as food, scybala, gallstones, 
or even worms (colica verminosa) . Again, as in gastralgia, it may be 
due to the distention of the bowel, either through impaction or gas 
(colica natulenta) . The latter follows the abnormal fermentation of 
starchy foods (e. g., green apples and also overripe fruits) . Cathar- 
tics may " gripe " the patient and cause colic. Abdominal chilling 
causes colic (colica rheumatica). On the other hand, we find colic 
in tabes dorsalis, uterine and ovarian inflammations, and lead poi- 
soning. Of course some cases of colic are due to simple hysteria. 

Hence, before treatment is begun, we must decide whether we 
have to remove irritant masses from the intestine or check re- 
flex pains. 

In the former cases it is always wise to use an enema to empty 
the lower bowel before any cathartic is given by the mouth. At the 
same time we may relieve any nerve spasm present by giving atropin 
mixtures. Thus the following mixture, recommended by Yeo, illus- 
trates a conventional combination of carminatives and sedatives • 

I> Tinctura? belladonna? oss ; 

Tinctura? cardamoni composite 3vj ; 

Spiritus ammonia? aromatici ^ __ ,_.. 

Spiritus chloroformi ) 

Sodii bicarbonatis 3 j ; 

Aqua? carui 1 ad §vj. 

Sig. Two tablespoonfuls every hour until relieved. 

1 For this caraway water, which is not officinal in U. S. P., may be substituted 
aquae menthae piperitae or the aquae aurantii florum in the same dosage. 



230 DISEASES OP THE DIGESTIVE TRACT 

Before such a prescription is given, however, if there is any 
reason to suspect that the offending material is still in the stomach, 
we should give an emetic and remove it. Thus T V grain apomor- 
phin hypodermatically would be the first thought in such a case. 

Following the drugs for immediate relief, one should use gentle 
cathartics for two or three days to make sure that the bowels are 
kept thoroughly emptied. Of these cathartics, calomel in J-grain 
doses (given every half hour until four to six are taken) and the 
salines (e.g., magnesium sulphate, 15 to 20 grams in water) are 
the best and least dangerous. 

In many cases the pain and distress will be so great that mor- 
phin must be given. In such cases it is better to give it with the 
needle and in a dose just large enough to dull the pain, but not 
large enough to check peristalsis; hence J grain should be the 
initial dose. 

The colic of infants is generally due to improper feeding, hence 
the food should be changed or peptonized until it can be cared for 
by the imperfect apparatus of the particular child under treat- 
ment. Rarely, indeed, can we prepare food for a class of infants; 
it is the individual that we must satisfy. 

The colic of hysteria is sometimes best relieved by asafetida or 
valerian. The former may be given by enema or by the mouth ; the 
latter is given as the ammoniated tincture of valerian in teaspoon- 
ful doses every half hour until relief is obtained. 

Lead colic is best treated by administering the sulphates (in 
order to precipitate the lead as it is excreted into the colon), as, 
for instance, in the following prescription (Yeo) : 

If Magnesii sulphatis j _- ^ 

Sodii sulphatis ) 

Acidi sulphurici aromatici 3 j ; 

Syrupi zingiberis o ss ; 

Aquse cinnamoni ad gxij. 

Sig. Pour teaspoonfuls every hour until relieved. 

Obstruction of the bowel requires early surgical interference, 
hence if the use of heat externally and by hot drinks, together with 
atropin, does not give relief, the surgeon should be called in. Irri- 
tant cathartics should not be used when there is a suspicion of 



THE INTESTINES 231 

intussusception (invagination). On the contrary, the bowel should 
be unloaded with copious enemata. The atropin usually makes 
the use of morphin unnecessary. 

Enteritis 

Usually nonspecific enteritis is due to dietary indiscretions lead- 
ing to the injury of the mucous surfaces by excessive fermentation 
or putrefaction. Again it may be due to the pathogenic bacteria 
that have worked their way into the bowel with the food. The 
disease therefore calls for the rest not only of the body as a whole, 
but also of the intestine itself. Therefore the patient should be 
put to bed and practically no food given by the mouth until the 
acute attack has subsided. 

The intestinal mucosa should be irrigated thoroughly by having 
the patient drink freely of weak mineral waters. If the inflam- 
mation be very acute, these mineral waters should be of a simple 
alkaline variety rather dilute ; but if the inflammation be subacute, 
then the more stimulant carbonated waters may prove more useful. 
They should be taken at least twice a day, preferably at 9 a.m. and 

4 P.M. 

Sufficient antiseptic drugs should be used to check the fermen- 
tation in the intestine, as well as the development of the specific 
organisms causing the trouble. For this purpose salol (two and 
one half grains) with calomel (one tenth grain) will prove very 
effective. For example: 

^ Phenylis salicylatis 0.2 

Hydrargyri chlor. mitis 0.01 

M. f. tabella no. I. Da tales doses XXV. Sig. One tablet 
every hour. 

One should expect, after forty-eight to seventy-two hours of the 
salol and calomel treatment, to find the stool green and inoffensive to 
the smell. In addition, one can use milk soured by the lactic-acid 
bacillus (e. g., lactone buttermilk) to assist in this action, the giving 
of this preparation to begin as soon as the milk causes no pain. 

If there be blood in the stool, indicating considerable erosion 
and ulceration, bismuth subnitrate should be given in sufficient 
quantities (e. g., ten grains stirred up in water taken on an empty 



232 DISEASES OF THE DIGESTIVE TRACT 

stomach at bedtime, early in the morning, and again during the 
day as needed) to coat over the abraded surfaces. Or, if one wishes 
to avoid the astringent action of the bismuth and secure a laxative 
effect, one may use olive oil (e. g., one half wineglassful at bed- 
time), if there be no great infection still present. 

The first food should be thoroughly predigested, or else there 
should be given with the food some digestant. Of these the best 
are the pancreatin compounds. For instance, diazyme or holadin 
are recommended as being particularly efficient. As in biliary 
troubles, so here, pancreatin ferments should be given about two 
and one half hours after meals. Lactone buttermilk, kefyr, yogurt, 
or koumiss may be given early in the disease in four- to eight- 
ounce quantities several times a day. Later, when the patient 
takes his three meals of mixed foods, such preparations may be 
given between meals; as, for instance, at ten o'clock, four o'clock, 
and at bedtime. For weeks the food should be nonirritating and 
should consist mainly of milk, steak, rare roast beef, tender fowls, 
mealy (dry) baked potatoes, toast (oven dried), fruit juices, etc. 

Sometimes there is considerable discomfort because of the for- 
mation of gas and the distention of the intestines. "When this can- 
not be relieved by high enemata with ox gall or other simple means, 
then the rectified oil of turpentine in five-drop doses, either on 
sugar or in a capsule, will usually be found sufficient to excite the 
peristalsis and carry off the gas. Asafetida in five-grain doses has 
also proven of value in such conditions. The cure of the tendency to 
distention comes only with the reestablishment of normal digestion. 

If there be a diarrhea and other indications of relaxed mucous 
membrane, medication in the form of albuminate of tannin (tan- 
nalbin) will be found useful. This should be given in the dosage 
of one half to one gram (five to fifteen grains) every two hours for 
three or four doses, then after each diarrheal stool. 

For the ileocolitis of infants, a writer {Medical Fortnightly, 
September 25, 1908) recommends: 

]$ Tct. cinnamoni 3 j ; 

Inf usi simarubre giij ; 

Syrupi aurantii q. s. ad g jv. 

Sig. One teaspoonful every four hours for an infant eight 
months old. 



THE INTESTINES 233 

This prescription for simaruba illustrates our tendency to add to 
our materia medica strange and fanciful preparations. Probably 
the standard drugs would be just as successful rightly combined 
and assisted by careful dieting and care. 

Flatulence 

Sometimes the abnormal formation of gas is the only indication 
of trouble in the intestinal canal, and it may be difficult, there- 
fore, to persuade a patient to undergo a course of vigorous dieting 
and intestinal cleansing. But in such cases the least that can be 
done is to require the patient to use nonfermentable foods (avoid- 
ing particularly those containing starch) and to drink water 
freely in order that there be something of a cleansing of the 
bowel. A course of mineral waters is usually more helpful than 
the plain drinking water. Of mineral waters, the alkaline cathar- 
tics are the ones most generally useful, and if there be any 
constipation, stronger waters, such as the Veronica, would be 
indicated. 

In the way of drugs, turpentine may be used to stop the fer- 
mentation and stimulate the peristalsis. Asafetida has considerable 
reputation for the relief of this disorder, having been used by the 
Hindus long before the time of Christ. This may be given in a 
pill of three to five grains, or as a suppository of similar size. Its 
effect seems to be due to its carminative and nerve-soothing action 
rather than to any particular local influence. 

Of course no cure can be accomplished if we cannot regulate 
the life and diet of the patient. When we can do this, we follow 
the principles laid down in our discussion of enteritis, except that 
frequently we need to give more bulky foods. In such cases we 
order salads, greens, sweet potatoes, and other vegetables rich in 
cellulose, mixing them with the other articles mentioned under 
Enteritis. We would avoid irritating spices, alcoholic drinks, etc. 
Even tobacco may have to be tabooed. 

The general habits of life of such patients should be active in 
order to stimulate and control the general circulation. In par- 
ticular, we should seek to drive the blood from the viscera to the 
extremities, and for this wood chopping would constitute an ideal 
combination of movements. For those then who will not or cannot 



234 DISEASES OF THE DIGESTIVE TRACT 

chop wood, tennis, active movements such as running, jumping, 
etc., are desirable. 

Typhoid Fever 

Typhoid fever is both an enteritis of specific origin and also a 
bacteremia with all the constitutional effects implied by the term, 
hence the treatment must observe the general principles laid 
down for cases of enteritis, and also combat the prostration and 
the tendency to the formation of secondary foci presented in 
septicemias. 

The patient is put to bed; no food is given that would in any 
way irritate the intestine or form a favorable medium for the 
growth of bacteria. Or, to put it positively regarding the food, 
one should feed the patient three to eight ounces of unfermented 
grape juice or sweet milk every three hours. Should the sweet 
milk prove indigestible (this can be seen by the presence of thick 
curds in the stool), either predigested milk or buttermilk should 
be given. 1 

If the patient can take additional food, the order of indulgence 
should be cream, toast, raw eggs (or eggnogs), lactose, etc.; but 
it should be remembered that the stools must be green and inof- 
fensive, there must be no gas pains or other disturbances due to 
the administration of too great an amount of food or to the general 
atony of the digestive organs. 

Some physicians advocate the feeding of patients ill with 
typhoid fever sufficient food to maintain their weight during the 
disease. Sometimes this may be done, but usually the ill effects 
accompanying the procedure, the relapses and prolongation of the 
convalescence limit sharply the number to which the method may 
be applied. 

An adult at rest produces about 30 calories of heat for each 
kilogram of his body-weight. At complete rest it may go as low as 
22 calories (Johannson). Typhoid patients are rarely at com- 
plete rest, hence their heat production may be put at 30 calories. 
In addition, ten per cent should be added for the dynamic stimula- 
tion of metabolism by food (Rubner). Now if in fever the heat 

1 See Virginia Medical Semi-monthly, April 9, 1909, and Archives of Internal 
Medicine, December 15, 1909. 



THE INTESTINES 



235 



production be increased from ten to sixty per cent (Krehl), we 
must estimate the outgo of energy in typhoid fever at about 53 
calories per kilogram (Shaeffer and Coleman). 

If, now, food affording 60 to 90 calories per kilogram of body- 
weight be given to patients ill with typhoid fever, the excretion of 
nitrogen may be kept within the amount ingested, especially if the 
greater part (all but 10 to 1.5 grams, which should be of nitro- 
gen) is given in the form of carbohydrates (Shaeffer and Cole- 
man). The foods used in the experiments leading to the above 
conclusion by Shaeffer and Coleman were the following: 



Food Used. 



Protein. 



Carbo- 
hydrate. 



Fat. 



Milk (by volume) 

Cream (by volume) 

Butter (by weight) 

Toast 

Eggs (weighing about 60 grams, gross) 

One egg 

Lactosi 

Somatose 

Liebig's meat extract 



Per Cent 



3.3 
2.0 



11.0 

12.0 

7.2 gm. 



12 . 4% nitrogen 
9.2% nitrogen 



Per Cent 
5.0 
3.0 



60.0 



100.0 



Per Cent 

5.0 
30.0 
85.0 

9.0 

5 . 4 gm. 



The fats proved indigestible, and an amount of protein greater 
than 10 to 15 grams afforded no greater benefit. 

In order to supply this greater amount of food, Houghton 
(American Journal of Medical Sciences, January, 1910) uses the 
following vegetable soup. One can carry out the principle by 
combining in the dietary with this soup eggs, cream, toast, milk, 
and grape juice, at two-hour intervals. 



The Preparation of Vegetable Soup. — Sixty grams each of green 
or canned French peas, white dry beans, potato, rice, and noodles, 
and 15 grams of carrot are boiled in water at least four hours. 
Sufficient water should be added to make one liter, which is suf- 
ficient for four feedings. The whole yields 760 calories, of which 
6.3 per cent is protein, fat less than 0.2 per cent, and 43.9 per cent 
is carbohydrate. When ready to use, stir up sediment and allow 
the patient to eat all (including noodles), with the exception of 
the pea and the bean skins. Onion may be added for flavor if 
desired. 



236 DISEASES OF THE DIGESTIVE TRACT 

% 
The drugs to influence the local condition are salol and 

calomel, used as indicated in our discussion of enteritis. Fre- 
quently physicians content themselves with giving dilute hydro- 
chloric acid, 15 to 20 drops in three to four ounces of water every 
four hours. This may be sufficient for uncomplicated cases, but it 
is better practice to secure the better intestinal conditions afforded 
by salol and calomel at the beginning of the treatment and thus be 
ready for any emergencies that may arise. 

The drinking freely of pure water is of great value. Thus the 
use of 4 ounces of water every half hour has often proven its worth. 

In this condition, on account of the presence of the ulcers in 
the ileum, it is important that no active peristalsis of the small 
intestine should be produced; therefore nearly all active catharsis 
should be brought about by colonic irrigation, using ox gall, if 
necessary, to stimulate colonic peristalsis. The colonic irrigation 
should be continued until the stools are free from offense. 

If the pulse become weak and irregular, showing a relaxed vaso- 
motor system, camphor should be used hypodermically, as indi- 
cated in our discussion of heart diseases (6 c.c. of the sterile ten- 
per-cent solution pro die). Camphor may also be given in the 
delirium accompanying typhoid, i. e., typhoid mania. 

Cold baths should be given frequently enough to stimulate the 
vasomotor control and also to keep the fever within reasonable 
limits. What such limits are depends upon the individual. Some 
patients can bear with impunity a temperature of 102° or 103° F. 
Others are extremely sick if the temperature goes above 101° F. 
The cold bath or sponge should be ordered according to the indi- 
vidual peculiarity of the patient. Under cold baths we do not 
necessarily mean tub baths, because the cold tub (Brand bath) is 
not usually necessary in typhoid. Probably just as good results 
can be obtained by the use of the cold sponge bath, and this with- 
out any danger to the patient. The technic of such a bath we 
have discussed at length under Fever. 

In case of perforation of the bowel, the only possible salvation 
is by means of immediate laparotomy. 

In case of hemorrhage, the foot of the bed should be elevated, 
ice should be packed over the abdomen, and tincture of opium 
in ten-drop doses should be given by the mouth, and also bismuth 



THE INTESTINES 237 

subnitrate or tannalbin in 10- to 15-grain dosage if more active 
astringents are needed. 

In order to prevent hemorrhage the calcium salts have been 
recommended. Thus Sir A. E. Wright recommends citric acid and 
salts to make the blood more fluid and calcium salts to make it more 
coagulable ; e. g., calcium lactate, 15 to 20 grains t. i. d. 1 

"We give usually calcium lactate in 15- to 20-grain doses every 
four hours, and thyroid extract, 3 to 5 grains t. i. d., on an empty 
stomach, whenever we fear hemorrhage or find the coagulation time 
becoming abnormally long. 

The prevention of the spread of the disease is an important 
part of the treatment. To this end the urine and stool should be 
covered with fresh milk of lime and let stand for a half hour be- 
fore being thrown into the closet or privy. All body and bed- 
clothing should be soaked in a five-per-cent solution of liq. cresolis 
co. of the Pharmacopeia for an hour or more. Dishes should be 
boiled. Nonwashable materials must all be disinfected with for- 
maldehyd. The disease spreads by the careless disposal of the 
feces, therefore patients should be kept under surveillance until 
three bacteriologic examinations of the stools, six days apart, prove 
negative. The last is Koch's rule, and it is one worth observing 
whenever we have the opportunity to study the stools bacteri- 
ologically. 

Colitis 

Colitis may be due to the presence of parasites, such as the 
ameba ; bacteria, e. g., bacillary dysentery ; to poisoning, e. g., 
excretion of the metals into the colon; and to nervous and nutri- 
tional disturbances, e. g., mucous colitis, membranous colitis. Thus 
we find that inflammation of the colon may result from stag- 
nation and putrefaction of the bowel contents (autointoxication), 
irritation from the ingestion of nonliving elements, and finally to 
the injury due to the presence of living organisms. 

The last type of colitis (mucous colitis), however, seems to have 
been so varied in its manifestations that some workers have classed 
it among the symptoms of general nervous derangement, while 
others believe that it is due to local irritation brought on by non- 

1 See The Practitioner, July, 1906; Quarterly Journal of Medicine (London), 
January, 1909. 



238 DISEASES OF THE DIGESTIVE TRACT 

hygienic living. In our judgment mucous colitis is due to both the 
nervous weakness and the local irritation. Thus women unhappy 
in their home lives, who have not been careful in the selection of 
their food or the ordering of their lives, constitute the majority 
of our patients suffering from mucous colitis. To cure such pa- 
tients it is necessary both to make them more contented and 
hygienic in their lives and also to relieve the local inflammation. 
Such patients suffer attacks of excruciating pain, followed by the 
discharge of feces containing mucous shreds and strings more or 
less bloodstained. 

We find that we need to inculcate in these patients a calmer 
outlook on life — more of stoicism, perhaps — in order that they may 
not be upset by their daily worries. Sometimes, in order to ac- 
complish this result, we must change their environment tempora- 
rily; for example, put them in a pleasant sanatorium for a few 
weeks. Secondly, we must stimulate their general metabolism by 
cold and hot baths and massage. Many of these patients have skins 
so particolored that it is evident that their bodies are full of 
the waste products of metabolism. With such patients the hot 
baths (either in the hot-air cabinet or in the tub) on alternate days 
should be used to start up increased elimination. But cold rubs 
should also be given mornings to stimulate the vasomotor system. 
At first such cold rubs must be given by an attendant; later the 
patients learn to give themselves fairly adequate treatments. 

The diet must be highly nutritious but bland. In this our ex- 
perience differs from that of von Noorden. We give steak and 
oven-dried toast, milk, buttermilk, eggs, and olive oil. Of the last 
we try to use at least two ounces daily. The meals may be at the 
usual hours, provided a lunch, e. g., of lactone buttermilk or yo- 
gurt, is given between each two meals. 

Laxatives should be given to prevent the stagnation of the feces 
and the formation of scybala, characteristic of this disorder. Min- 
eral waters (preferably of the heavily mineralized type, such as 
Veronica, Saratoga Congress, etc.) should be used once or twice a 
day on an empty stomach. In addition, phenolphthalein should 
be used in sufficient quantities to insure two evacuations daily. 
This should be given at night, and, if given in tablet form, should 
be well chewed before being swallowed. One or two grains a day 
may be needed. 



THE INTESTINES 239 

Usually the use of ox gall and pancreatin to promote intes- 
tinal digestion is of assistance at the beginning of treatment. 
Thus capsules containing one to two grains of ox gall and 
similar amounts of pancreatin should be given two hours after 
meals. 

Finally, the colon should be irrigated daily with normal salt 
or soda solutions. This irrigation should be done with the thirty- 
inch soft rubber colon tube. If it is done right, the procedure is 
of much value, otherwise it is useless. To carry out the procedure, 
the patient should lie on the left side on a Kelly pad, with knees 
drawn up. The tube should be lubricated with petrolatum and 
gently inserted. As soon as resistance is met, the water should be 
turned on in order to belly out the gut in front of the tube, and the 
tube pushed forward with a gentle rotatory movement until it has 
reached beyond the sigmoid flexure. The flow of the solution 
should be stopped if either it gives pain or the colon is visibly dis- 
tended. The patient should hold the solution for fifteen to twenty 
minutes before trying to expel it. Longer retention is helpful 
rather than harmful. 

i The prognosis in these cases is poor unless one can secure the 
conditions necessary for carrying out the treatment for a long time 
or until the colon have recovered its ability to absorb and trans- 
mit without the excretion of the tenacious mucus, hence we should 
be careful at the beginning to stipulate the conditions of cure as 
well as its difficulties. 

Toxic Colitis. — The use of arsenic is always attended with the 
danger of poisoning from its excretion and reabsorption in the 
large intestine. The other metals are subject to the same dangers 
as far as the local irritation of the bowel is concerned ; hence when- 
ever patients are being given the metals it is well to prescribe 
colonic irrigations as well as laxatives to insure the daily cleansing 
of the bowel. This same precaution would be useful with workers 
in lead and other metals. 

When the inflammation is already present, the first indication, 
of course, is to stop the ingestion of the irritant. The next is the 
thorough flushing of the bowel by water and salines per os and 
per rectum. When considerable tenesmus is present, olive oil 
should be freely administered both per os (after food) and per 
rectum (warm, with the patient lying with elevated hips). The 
17 



240 DISEASES OF THE DIGESTIVE TRACT 

use of atropin will assist in overcoming much of the discomfort 
resulting from the irritation. This may be administered as the 
tincture of belladonna per os in ten-drop doses, or subcutaneously 
in doses of y-^ to ^V grain of atropin. 

The putrefactive and bacterial inflammations require first of all 
rest, then irrigation; that is, the patient should rest in bed a 
goodly share of the time during the acute attack. The diet also 
should be of such a type as to afford rest to the colon. For in- 
stance, the foods mentioned above (lean meats, eggs, milk, etc.) 
are usually chosen as the basis of the diet. Food containing 
cellulose should not be used until the acuteness of the attack 
is past. 

The irrigation should be given both by drinking ten to fifteen 
glasses of water daily, e. g., one every hour, as well as by the daily 
colonic flushing. The solutions for the latter should not be at all 
stimulant or irritant — the normal saline or soda solutions are gen- 
erally best ; but to be effective they must be put in high up. While 
the bowel is irritated (shown, for instance, by the passage of blood- 
stained feces) starch or oil enemata or tannin solutions may be 
needed, the first two to coat the denuded areas, the last to act as an 
astringent (two-per-cent solution). 

After the acute stage is past, " greens " of beet tops, chard, 
etc., may be added to the diet to act as a nucleus of a mass for 
sweeping out the colon. 

In the way of drugs, two types may be indicated. Either there 
may be need for the antifermentatives and antiseptics, such as 
salol and hexamethylenamin, or the intestinal ferments, such as 
pancreatin and papain, to carry the food beyond the reach of 
the putrefactive organisms. Should the digestants be used, they 
should be administered at least an hour before meals. Which 
type should be used may be decided upon by examining the stools 
to ascertain whether the intestinal digestion seems complete, and 
whether evidences of putrefaction (skatol, indigo) are present; 
for, if there be evidences of lack of digestive power, holadin and 
bile salts, or some similar preparation, should be used. If putre- 
faction be pronounced salol or hexamethylenamin should be ad- 
ministered. 

We shall consider parasitic colitis under the general head of 
Intestinal Parasites following. 



THE INTESTINES 241 

Intestinal Parasites 

In general for the treatment of this disorder it will be found 
necessary to give a diet that will free the bowels of as much food 
detritus as possible, in order to leave the parasites exposed to the 
action of such drugs as may be given. The drug treatment is 
directed toward intoxicating the worm without giving sufficient 
of the drug to intoxicate the tissues of the host. It is well, there- 
fore, to give the drug in such a way that as little as possible of it 
is absorbed; as, for instance, after the bowel has been cleansed by 
catharsis and just before more cathartics are given. For the dif- 
ferent kinds of parasites different drugs are used. 

Another method of attacking the parasites is shown by the late 
reports of the successful use of papain. This, of course, consti- 
tutes an effort to digest the parasites without any particular effort 
at specificity. Of this drug, one would use five grains in gelatin 
capsules every three hours, taken with a glass of water. 

Tenia. — The tenia are usually most efficiently removed by us- 
ing preparations of the male fern. The night preceding the 
planned medication, the patient should be given a very light meal. 
Sometimes it seems best to make this meal of salads, sardines, and 
mixtures of cellulose and oil m order to stimulate the peristalsis 
and carry down in the general mass the parasites also. The next 
morning, before breakfast, 8 c.c. of the ethereal extract of the 
male fern are given in divided doses; that is, 2 c.c. in gelatin cap- 
sules every fifteen minutes. Fifteen minutes after the giving of 
the last capsule a brisk saline cathartic, or calomel and jalap, is 
given. The use of castor oil for this purpose is a questionable 
procedure, because the oil tends to make the male fern more easily 
absorbed, and thus there is a liability to systemic intoxication ; but 
nevertheless the oil is frequently given — one tablespoonful floated 
on a cup of black coffee. The stools should, of course, all be care- 
fully collected and examined by washing them through a fine sieve 
to see if the head of the worm as well as the body has been brought 
away. If the head cannot be found in the sieve, it is well to repeat 
the treatment after the lapse of a fortnight. 

Instead of the ethereal extract of male fern, it is often easier 
in America to secure the oleoresin. We should then use the fol- 
lowing prescription: 



242 DISEASES OF THE DIGESTIVE TRACT 

IJ Oleoresinae aspidii 8.0 

Da in capsulis gelat. no. IV. Sig. One capsule every fifteen 
minutes, followed by a wineglassful of Pluto water (or one ounce 
of Epsom salts). 

Ameba Coli. — This parasite usually inhabits the cecal end of 
the colon, and because it burrows underneath the mucosa is very 
difficult to dislodge. Daily high (thirty-inch tube) colonic flush- 
ings with a 1 : 500 solution of quinin bisulphate will be found best 
to begin with. Later the strength of the solution should be re- 
duced to 1 : 1,000. If there is a dysentery, solutions of tannin 
(two per cent) may be employed in alternation with the quinin. 
Large meals of greens (for instance, beet tops) seem to have some 
value in acting as a mechanical brush to cleanse the intestines of 
the parasites; otherwise the diet should be light (small meals at 
short intervals). In particular, the food should be such that no 
masses be formed in the intestine in which the parasites could 
burrow. 

Calomel, one grain a day in divided doses, seems to be of assist- 
ance in removing the parasites in some cases. In others, powdered 
thymol, ten grains a day in capsules, has been successful. Ipecac 
in salol-covered capsules, in doses of sixty grains a day, has given 
great satisfaction in the British army and in the Philippines. 1 It 
may be given also in divided doses. But in spite of all these meas- 
ures, it is sometimes necessary to perform a caecostomy and insert 
a permanent catheter and thus secure the opportunity to irrigate 



1 "The detailed method of its administration is, I believe, of the greatest im- 
portance, the lack of which stands as explanation in part for the failures reported 
in many quarters. First of all, the drug should be administered only in pill 
form, coated to the extent of about one eighth inch with phenylsalicylate (salol). 
The patient must be put to bed for the first two weeks' treatment and his diet 
restricted to liquids, or at most light solids. This absolute rest in bed with re- 
stricted diet is particularly essential to the details of the plan. Castor oil may 
be given as the initial purgative and then each evening, after a three-hours' fast, 
the salol-coated pills are administered. A start may be made with 40 or 60 
grains, depending on the length or the severity of the infection, but each sub- 
sequent evening the dose is reduced 5 grains until the limit of 10 grains is reached. 
Following this I have been in the habit of continuing with 10 grains each day for 
the next two weeks." — Simon, in The Journal of the American Medical Asso- 
ciation, p. 1529, Nov. 6, 1909. 



THE INTESTINES 243 

the colon satisfactorily from above. Here one uses the same solu- 
tions as for the irrigation from the rectum. 

The Hook Worm. — The uncinaria occupy the duodenum and are 
therefore best reached by drugs given by the mouth. Thymol is 
regarded practically as specific, although male fern is also quite 
efficient. The former is given powdered in capsules to the amount 
of thirty grains within three hours, followed by brisk catharsis, 
according to the following prescription: 

Tfr Thymolis pulv 2.0 

Pone in capsulis no. III. Sig. Take one capsule on empty 
stomach, every half- to three-quarter-hour, and follow the last dose 
with one ounce Epsom salts in four ounces water. 

The treatment should be preceded for a day or two by a prelim- 
inary dieting to clear ^the intestine of fecal masses and fermenting 
foods. During and after the administration of the thymol, coffee 
should be given to prevent collapse, because thymol is apt to cause 
collapse if absorbed by the intestinal walls. It is therefore im- 
portant that the patient be carefully watched during the exhibition 
of the drug and that it be followed by a cathartic to prevent any 
such dangerous prostration. 

The constitutional conditions accompanying uncinariasis are 
combated by the exhibition of iron in the form of Blaud's mass 
(five grains three times a day). Because Blaud's mass deteriorates 
with age, it is better, when one is not sure of obtaining freshly pre- 
pared pills, to order the saccharated ferrous carbonate in cap- 
sules, thus: 

j^ F err i carbonatis saccharati 15.0 

Da in capsulis gelat. no. L. Sig. One capsule t. i. d. 

Pin Worms. — Pin worms, or seat worms, are usually found in 
the lower colon and in the rectum. They may be removed, there- 
fore, by thorough irrigation from the rectum. Salt solution is 
usually quite efficient for such irrigation, although quinin bi- 
sulphate solution may be needed (1:1,000). 

The favorite drugs for use by the mouth are calomel and san- 
tonin. These are given in doses of one half grain of each every 
fifteen minutes until three or four doses are given, followed, if 
necessary, by a saline purge. 



244 DISEASES OF THE DIGESTIVE TRACT 

IJ Hydrargyri chloridi mitis 0.12 

Santonini 0.12 

M. Da in capsulis (vel tabellis compressis) no. IV. Sig. 
One capsule (or tablet) on an empty stomach every fifteen 
minutes. 

Round Worms. — These occupy the small intestine and are most 
easily removed by santonin and calomel. On the night preceding 
the treatment, the food should be limited in quantity and should 
consist largely of oils or salads, then in the morning, on an empty 
stomach, one half grain each of santonin and calomel should be 
given every fifteen minutes until four doses are taken. This is 
usually sufficient to expel these parasites. 

Enteroptosis 

The sinking of one or all of the viscera of the abdomen is prov- 
ing to be a causative factor in many cases of constipation, gastric 
dilation, and nervous disorders, hence it deserves some attention. 
As a rule, enteroptosis seems to be due to congenital conditions, 
and is found chiefly in long, narrow-chested (phthinoid) indi- 
viduals with weak abdominal musculature. The condition de- 
velops into one of pathologic importance when disease or lack of 
exercise robs the patient of his reserve strength. The organs then 
sink down until they receive some support from below; that is, 
practically into the pelvis. This, of course, interferes with their 
function and also causes discomfort by dragging on their support- 
ing ligaments. 

The treatment must first of all seek to restore strength to the 
musculature and ligaments. During this time the disturbed func- 
tion must be performed by artificial aid (digestants, bandages, 
etc.). Finally, when necessary, mechanical supports must be used 
to keep the organs in place. 

For the first, the general condition of the patient must be 
improved. Usually it is necessary to put the patient to bed 
and give considerable massage to the abdomen to relieve the 
organs of their congestion and restore them to their pristine 
vitality. Such a course of treatment lasts ordinarily from four 
to six weeks. 



THE INTESTINES 245 

The bed rest and dieting are important in relieving the fatigue 
and securing a new general vigor for the entire body. The result 
of the treatment is generally a restoration of tone to the circulation 
(that is, the hands and feet lose their tendency to be cold and 
clammy) and a feeling of fitness for living before absent. The 
massage develops strength in the muscles and restores some part 
of their contractility to the ligaments. 

Only when such measures fail should abdominal supporters, 
such as belts and corsets, be resorted to, for these permanently 
weaken the ligaments and make the patient entirely dependent 
upon such outside support. In this same category comes sur- 
gical interference, such as suspension and gastroenterostomy 
and bowel exclusion. Such operations are the final resort, after 
we have failed to establish a hygienic life and muscular com- 
pensation. 

During the treatment it is usually necessary to use saline laxa- 
tives, diuretics, and even vasomotor tonics to overcome the portal 
congestion, with its accompanying indigestion and constipation. 

Pancreatitis 

We are just beginning to learn something of the diseases of the 
pancreas, and we find that they are of two types. Either there is 
an inflammation of the parenchyma of the organ, or there is a 
cyst formation due to the obstruction of its ducts. Inflammatory 
material may be brought there by the blood, but usually it is de- 
rived from the duodenum through the duct. 

In the treatment, drugs should be used to keep the duodenum 
free from stagnation in and about the opening of the duct. Pan- 
creatic extract must be supplied per os to take care of the food 
for the body while the pancreas is out of commission, and also 
drugs should be used to check any fermentation of bacterial growth 
within the limits of the gland. 

These indications are met in the same manner as the correspond- 
ing inflammations of the gall bladder. Thus mineral waters are 
given, as are also ox gall, some preparations of pancreatin, salol, 
hexamethylenamin, and calomel in practically the same way. For 
instance, the following prescription will be found useful at the 
onset and while the pain is pronounced: 



246 DISEASES OF THE DIGESTIVE TRACT 

tf Fellis bovis . . 0.1 

Pancreatini 0.1 

Hexamethylenaminse 0.05 

Acetphenetidini 0.1 

Hydrargyri chlor. mitis 0.01 

M. f. caps, gelat. no. I. Da tales doses no. XV. Sig. One 
capsule every two hours. 

Holadin with bile salts would also prove effective in the place of 
the two first ingredients, or, where there is little pain and fever, 
they might constitute the only remedy given. 



Peritonitis 

Peritonitis is a bacterial inflammation originating usually from 
the discharge of intestinal contents into the peritoneal sac. This 
occurs chiefly through the perforation of ulcers, as in typhoid 
fever, peptic erosion, etc., but may also occur through the transmis- 
sion of bacteria through the intestinal wall without open perfora- 
tion, as in case of intestinal tuberculosis. Similarly, pelvic peri- 
tonitis is a frequent accompaniment of infection of the uterus and 
tubes, due to the escape of the infectious material into the peri- 
toneum, as from gonorrhea or puerperal fever, hence in nearly 
all cases peritonitis is secondary to some other localized inflamma- 
tion, and occurs only when the primary infection has not been suc- 
cessfully checked. This causation logically makes the treatment 
of peritonitis largely symptomatic, although sometimes surgical 
interference may seem to assume the appearance of causal treat- 
ment; for real causal treatment must be directed toward combat- 
ing the primary lesion. 

The symptoms usually are intense abdominal pain, distention 
and tympanites, obstipation, rapid and shallow respiration, vom- 
iting, scanty urine, etc. The patient lies with knees drawn up, 
pale and anxious countenance, either rapidly sinking into a coma 
or tending toward delirious excitement. 

In perforative peritonitis successful treatment demands imme- 
diate laparotomy and closure of the perforation, with a subsequent 
drainage (perhaps also with a saline flushing) of the peritoneal 



THE INTESTINES 247 

sac. 1 Even in other cases the surgical interference may be justi- 
fied ; but, if done at all, it should be done at the beginning of the 
inflammation, hence an early and sure diagnosis, with quick de- 
cision, adds much to the prospect of success. 

The treatment, whether with or without a laparotomy, demands 
(a) rest, (6) the application of heat (or cold), (c) the flushing of 
the system with normal saline solution, and (d) gastric lavage and 
the relief of vomiting and shock. 

Rest should include bodily rest as well as the rest of the in- 
testines, hence the patient is kept quiet and no food given by the 
stomach. If there be no danger of shock, ice is applied to the ab- 
domen; if there be weakness indicating a liability to shock, heat 
is applied. This both relieves the pain and relaxes the intestines. 
Heat is best applied with the thermophore, but where that is not 
available, hot fomentations may be used. The patient should be 
allowed to lie in any position he desires, so long as he be kept quiet. 

The salt solution supplies the body with fluid and tends to 
promote diuresis, as well as diaphoresis. In this way it removes 
toxins from the system ; it is, therefore, the most important aggres- 
sive treatment in this disease. It should be given by the rectum, 
and, as long as the patient can retain it, as much as a pint every 
hour. If the patient seems unable to retain it the continuous proc- 
toclysis of Murphy (see Fig. 42) should be resorted to. In this 
method the solution is allowed to run into the bowel at just above 
body temperature, with the reservoir just high enough to permit 
an interchange of fluid between the bowel and reservoir, as the 
force of bowel peristalsis varies. This irrigation also prevents 
thirst and shock, thus doing much to assist the body to fight the 

1 The following is Mayo Robson's summary of the plans of surgical inter- 
ference : 

" (1) The removal or repair of the cause with or without irrigation of the 
peritoneal cavity; (2) drainage of the site of operation by a split rubber tube 
containing a strip of gauze, and of the peritoneal cavity by a tube in the pelvis, 
assisted by the reclining posture, which he has for years advocated after all 
abdominal operations; (3) rapidity of operation; (4) avoidance of unnecessary 
exposure and handling of the viscera; (5) the prevention of shock; (6) the free 
administration of saline fluid by the rectum; (7) rectal alimentation and the 
stoppage for a time of mouth feeding; and (8) the avoidance of opium and some- 
times the administration of repeated small doses of calomel subsequently to 
operation." 



248 



DISEASES OF THE DIGESTIVE TRACT 



disease. Whenever it is impracticable to use the bowel, the saline 
solution 1 should be introduced subcutaneously into the loose tis- 
sues of the chest and flanks. For this the solution (and vessels) 




Fig. 42. — Appaeatus for Continuous Proctoclysis. 
The cylinder is for the purpose of keeping the solution at an even temperature. 

must be sterile and the fluid kept at about 110° F. One pint may 
be introduced at a sitting; thus two or three pints may be intro- 
duced in twenty-four hours. 

The distressing vomiting and peristaltic frenzy are kept in 
abeyance by careful gastric lavage. For this the patient does not 
need to be upright, but should swallow the tube in his usual posi- 
tion in bed. Only enough water should be used to secure a good 
cleansing of the stomach. 

For vasomotor stimulation and control, the subcutaneous in- 
jection of camphor dissolved in sterile oil, and also of strychnin, 
will prove useful. Of the former, 6 c.c. should be used daily; of 
the latter, -^ grain every four hours. 

Opium should be used only as a last resort. It masks the symp- 
toms and checks excretion, hence it does not, like the above meas- 
ures, tend toward cure while affording relief. 



1 See note on normal solutions on p. 453. 



THE INTESTINES 249 

In cases of pelvic peritonitis one may, in addition to the above, 
flush out the vagina (and the uterus, if circumstances permit) with 
one-fourth-per-cent lysol solution at 110° to 120° F. This irriga- 
tion may be done twice a day. 

In cases of tuberculous peritonitis we find very different con- 
ditions, and must proceed differently. Thus one should use ex- 
ternally iodin or iodoform ointment (Yeo). This is made of one 
half grain of iodoform dissolved in a dessertspoonful of cod-liver 
oil. It should be well rubbed into the abdomen three times a day. 
At the same time iodoform should be given by the mouth, accord- 
ing to the following prescription: 

IJ Iodof ormi gr. ss ; 

Ext. nucis vomicae " J ; 

Mentholis " i- 

M. f. caps, gelat. no. I. Sig. One capsule three times a day 
after food. 

The presence of the iodoform, even when given only by inunction, 
is to be demonstrated in the urine in from two to four hours' time 
(Still) either as iodin or iodid, hence the well-known remedial in- 
fluence of the iodids on tuberculosis is brought to bear to its fullest 
extent when given in this way in tuberculous peritonitis. 

If medical treatment for tuberculous peritonitis does not show 
improvement in four to six weeks, a laparotomy should be done 
and the peritoneum drained. The mere entrance of air into the 
sac seems to be sufficient to stimulate the tissues toward repair, 
therefore some operators leave rather large drainage tubes in the 
wound in order to continue this influence. 

In other cases of tuberculous peritonitis guaiacol (equal parts 
of guaiacol and olive oil) seems to be very effective when rubbed 
into the abdomen ; in fact, in nearly all cases of peritonitis the in- 
unction of guaiacol will be found to give great relief, both from 
the pain and the high fever. It should be applied from three to 
six times a day. 

When the peritonitis is not extremely acute, and where the 
patient can take food and medicine by the mouth, it is wise to pre- 
vent fermentation and distention in the intestine by giving salol 
in full doses. This also renders the body fluids less efficient as 



250 DISEASES OF THE DIGESTIVE TRACT 

culture media, and in that way tends toward shortening the time of 
inflammation. 

Diseases of the Rectum 

Hemorrhoids. — The first indication here is to secure relief from 
pain; the second is to get rid of the cause of the pain, namely, 
the dilated capillaries and local congestion. The first is brought 
about by the application of some local analgesic, such as atropin, 
menthol, or phenolated camphor. Even cocain, eucain, or quinin 
hydrochlorid and urea may be injected under the mucosa in very 
dilute, e. g., one-half -per-cent, solution, and thus afford the con- 
ditions necessary for the surgical treatment of the disorder. 

Probably some form of radical treatment like complete excision 
is the most satisfactory and efficient method. The palliative meth- 
ods of treatment by the use of suppositories containing tannin, 
belladonna, and alum, or similar drugs, will do only for subacute 
and very mild cases. It rarely, however, is a profitable method of 
treatment. 

We suggest, then, that the patient be put on a table or solid bed 
and the rectum either swabbed with the following solution or a 
tampon saturated with it packed against the inflamed surfaces : 

^ Morphinae 1.0 

Atropinae 0.1 

Glycerini 10.0 

Aquas 10.0 

After about ten minutes we may proceed to inject eucain in two 
per cent, cocain in two per cent, or quinin hydrochlorid and urea 
in one-half -per-cent solution along the line of incision. 

The following is Dr. Heitzman's description of his operation, 
which is a useful one for office work for the removal of hem- 
orrhoids : 

After the preparation of the patient, the tumors are exposed suc- 
cessively and held between the thumb and finger or with forceps. An 
incision is then carried in the long axis of the bowel through the mu- 
cous membrane, care being taken not to wound the blood vessels. The 
blood vessels being now exposed, they are grasped with forceps and trac- 
tion applied. This, as a rule, will liberate the vessels; if not, the use 
of a small blunt spoon or curette will materially assist in breaking up 



THE INTESTINES 251 

the inflammatory adhesions of the connective tissue. When by this 
method the hemorrhoidal vessels are thoroughly exposed through the 
cut in the mucous membrane, a ligature of small-sized catgut is applied 
above and below. Now the vessels are extirpated with scissors or knife. 
The incision in the mucous membrane is closed with like suture ma- 
terial. I have found, however, that unless the incision is large it heals 
just as readily without suturing, being hermetically sealed with blood 
clot. Should too much redundant tissue remain it may be removed, 
carrying the incision in the form of an ellipse and closed as before. 
It is surprising, however, how much the mucous membrane will shrink 
after removal of the vessels. The only dressing used is a sterile pad 
over the anal region. The operation is best performed without the use 
of sponging, a drip of boric-acid solution being employed to keep the 
field clean. 

Limitations. — The operation is not applicable to the friable or capil- 
lary form, nor to the so-called connective tissue or cutaneous hemor- 
rhoids. 

Superiority of the Operation. — It is at once thoroughly surgical as 
well as simple. There is little hemorrhage during the operation, and 
the danger of secondary hemorrhage is reduced to a minimum. It is a 
comfortable operation for the patient; there is practically no pain. 
The edges of the wound are thoroughly coapted, causing prompt healing 
and the absence of a cicatrix. Tl*e cause is removed, not merely a 
bunch of mucous membrane, as is often the case with other operations; 
therefore the probabilities of recurrence are limited, more so than with 
other operations, to say nothing of unfortunate sequelae such as I have 
mentioned. 

Fistulse and Fissures. — We have practically considered these in 
our discussion of the inflammations of mucous membranes, but in 
order to make the subject more complete, we recapitulate the dis- 
cussion here. The first indication is to stop the irritation due to 
the broken mucous membrane and the exposure of the sensory 
nerves, and the second is to cover over the abraded surface in order 
that it may heal without interference. Whenever we can reach the 
fissures with a probe or swab we should apply either silver nitrate 
or carbolic acid in full strength, destroying any germ life present, 
forming an eschar, and thus preventing the spreading of the in- 
flammation to the surrounding healthy mucous membrane. Where 
a caustic action is not desired, atropin may be used to deaden the 
sensory nerves, applied in a one-per-cent solution. 



252 DISEASES OF THE DIGESTIVE TRACT 

If there be a considerable surface abraded and exposed, which 
cannot be easily treated with a probe, as, for instance, in the am- 
pulla recti or in the upper part of the anal canal, then tannin in a 
ten-per-cent solution will be found useful for injection. Such in- 
jection should be put in slowly and allowed to remain in contact 
with the tissues as long as possible. For this very reason supposi- 
tories and soothing ointments are preferred to simple injections in 
such erosions, because they not only keep the drug in contact with 
the inflamed area a long time, but they also protect the surfaces 
from irritation. The following is the formula of a commercial 
suppository : 

J$ Opium, powdered 1 gr. 

Ichthyol 2i " 

Tannic acid 1 " 

Extract belladonna J ' ' 

Extract stramonium \ " 

Extract hyoscyamus J ' ' 

Extract hamamelis £ ' ' 

Phenol i " 

Excipients in sufficient quantity to make one suppository. 

This illustrates the tendency to include in such a prescription 
all possible sorts of drugs — " shotgun prescribing." 

Another prescription, and one much more logical, is: 

^ Bismuth subnit 6.0 grams. 

Resorcinol 0.5 " 

Balsam peruv 1.5 " 

01. theobrom 19.0 " 

Ung. cerat 2.5 " 

M. f. suppos. no. XII. 

This avoids the use of morphin, atropin, and similar systemic drugs. 
In caustic action there are three stages to be distinguished : the 
simple hyperemia, the inflammatory necrosis, and the chemic solu- 
tion. The scab (eschar) is liquid or hard and dry, according to the 
chemical combination formed by the particular caustic in use. 
Solid scabs prevent the deeper penetration of the drug. In general, 
it may be said that the metals give hard scabs, while the alkalies 



THE INTESTINES 253 

give soft ones. It may also be stated that the acids act by with- 
drawing the water. Sulphuric, trichloracetic, and nitric acids act 
by carbonizing the tissue, because they break up the molecules, 
thus separating the hydrogen and oxygen. Silver nitrate forms a 
hard scab, phenol a soft one. 

For these reasons in rectal work silver nitrate or pure crystal- 
line phenol (or phenol liquefied by heat, never phenol in aqueous 
solution) are the caustics generally used. After using phenol, one 
should always touch the parts with alcohol in order to remove the 
excess. It is generally good policy to precede such cauterizations in 
the rectum by the application of a local anesthetic, as noted above. 1 

It goes without saying that inaccessible fistulse should be made 
accessible by the use of the knife under an anesthetic and then 
treated with the caustic or the diseased tissue excised, as may seem 
best to the operator. The spasm of the sphincters that nearly al- 
ways accompanies abrasions of the anal mucosa needs to be over- 
come at the beginning of the treatment. This may be accomplished 
by dilation under an anesthetic or, more slowly, by the use of 
belladonna suppositories. As soon as the dilation is accomplished, 
the use of the silver nitrate to coat over the denuded areas will, 
in most cases, prevent the return of the spasmodic contraction. 

Defecation is a painful process for these patients, therefore, 
wherever possible, this should be alleviated by using daily oil 
enemata. Where such local treatment is not possible, mineral 
waters or saline laxatives should be given to keep the stool soft. 

Pruritus Ani. — This condition is most often due to a lack of 
nutrition of the tissues due to the changes of old age, but it may 
also accompany the eczema ani due to the irritating secretions of 
chronic diarrhea ; hence the first step is to correct the bowel condi- 
tion. This is best done by daily irrigations with quinin bisulphate 
and tannin solutions (the former in 1 : 1,000, the latter in two-per- 
cent solution). At the same time papain and a tannin albuminate 
should be given by the mouth. 2 

1 The student will find much valuable information and suggestion along this 
particular line in Hilton's "Rest and Pain." 

2 ]$ Tannalbin 0.1 gram. 

Papain 0.2 " 

M. f. caps. no. I. Da tales doses no. XX. 
Sig. One capsule one hour after each meal. 



254 DISEASES OF THE DIGESTIVE TRACT 

The application of high-frequency currents and the bidet 
spray will then tend to restore the nutrition of the skin. Such 
treatments should be given at first daily, gradually lengthening the 
interval as the relief is obtained. 

Finally, for symptomatic relief, ointments may be used. For 
instance, an excellent ointment for this affection contains: 

IJ Camphor 4 gr. ; 

Menthol 3 gr. ; 

Carbolic acid \ dr. ; 

Boric acid 

Calomel aa 10 gr. ; 

Zinc oxid q. s. ad 1 oz. 

But the painting of the inflamed area with a two-per-cent solu- 
tion of nitrate of silver will be more successful than the use of 
ointments. This painting may be repeated every day or every 
other day, as needed. 



CHAPTER V 

DISEASES OF THE CIRCULATORY SYSTEM 

THE HEART 

This discussion includes the disorders not only of the heart 
muscle itself, but those also of the pericardium and the endo- 
cardium, together with the cardiac neuroses. 

The Neuroses 

Probably one of the most painful diseases classified under heart 
disease is the so-called angina pectoris. This seems to be simply 
a nervous spasm of the coronary blood vessels. Since it is a nerv- 
ous spasm, the therapeutic indication is for a drug that shall in- 
hibit the nerve centers that cause such a spasm. The drug ordi- 
narily used is a nitrite, either in the form of the amyl nitrite or 
nitroglycerin. The former is inhaled in the dosage of three drops, 
usually by breaking in a handkerchief a glass pearl containing that 
amount; the latter is injected hypodermically in the dosage of y^ 
to ^o of a grain. Another drug that will help in this condition is 
atropin, injected hypodermically in y^-grain to -^pgrain doses. 
The nitrites act more quickly than atropin, hence it is useful some- 
times to give both the nitroglycerin (glonoin) tablet and at the 
same time the atropin. 

Palpitation is another troublesome cardiac neurosis. This may 
be due to reflexes from the viscera, to pressure from neighboring 
organs, and to mental conditions; hence to treat palpitation one 
must locate the cause of the nervous excitement. 

Of the reflex conditions causing cardiac palpitation, perhaps 

enteroptosis is the one most frequently found at fault. In other 

cases the patient's indigestion seems to be sufficient to cause the 

trouble ; and in general we find that the splanchnic and abdominal 

18 255 



256 DISEASES OF THE CIRCULATORY SYSTEM 

sympathetic nerve centers are being irritated by some such strain- 
ing and stretching of the tissues whenever the palpitation is the 
result of a visceral reflex. Here atropin, to relieve the cardiac 
excitement, would be the first drug to consider. Its use is gener- 
ally sufficient to relieve the symptom; then comes in the causal 
treatment — a matter that, as in the case of enteroptosis, is not so 
easy. This involves, for instance, the correction of the visceral 
ptoses and allied conditions. 

Hence in most cases the physician must content himself with 
giving remedies to relieve the attacks of palpitation and advising 
in general terms the correction of dietary and hygienic errors, and 
the use of appropriate gymnastic exercises. 

In the case of palpitation due to simple acute gastric distention 
we should empty the stomach if the danger be great. This may 
be done with the stomach tube or apomorphin ( T V grain subcu- 
taneously). In milder cases, twenty to thirty drops of dilute hy- 
drochloric acid, well diluted in water, will be found sufficient to 
relieve the distention. 

If the palpitation be due to the pressure of tight clothing the 
remedy is obvious. 

In the palpitation due to general nervousness, the bromids will 
be found useful. Fifteen grains of sodium bromid in a half glass 
of water will ordinarily be sufficient to depress the excited spinal 
centers sufficiently to allow the normal cardiac rhythm to reap- 
pear. If more prompt action is desired (for the bromid action 
might not appear within an hour), the bromid could be profitably 
given with the ammoniated tincture of valerian, e. g. : 

Sodii bromidi 10 

Ext. fl. Valerianae 10 

Arom. spts. ammon 40 

Aquaa destill 40 

Sig. One dessertspoonful, well diluted, every hour until the 
patient is quiet. 

To summarize the above : The treatment of palpitation must be 
considered under the heads The Immediate Relief and The Re- 
moval of the Cause. Thus, while we secure temporary (and neces- 
sary) relief by means of atropin or the bromids, we must not forget 



THE HEART 257 

that these drugs should not be given for any length of time, but 
should remember that they should be replaced by dietetic, hygienic, 
or other drug treatment, as each case may demand. 

In a similar way tachycardia and bradycardia must be pro- 
ceeded against. Thus in the tachycardia of exophthalmic goiter 
heart tonics and depressants are nearly useless, having at most 
an evanescent effect. On the other hand, drugs that combat the 
toxemia producing the tachycardia permanently affect the condi- 
tion. Therefore, instead of using aconite, ammoniates, or digitalis 
for such a patient, one would better use the quinin hydrobromid 
recommended by Forchheimer or the thyroidectin recommended 
by other observers to overcome the hyperthyroidism lying at the 
basis of the disorder. Rarely is the tachycardia so acute that the 
delay of the few days in which such treatment would take effect 
would prove fatal. 

Pericarditis 

Whenever the pericardium is inflamed there may be an effusion 
into the pericardial sac, and this may interfere with the regularity 
of the action of the heart. When there is no such effusion the ap- 
posed surfaces are dry and irritated, or even adherent. We must 
therefore see to it that the pain is relieved, that the heart's action 
is kept regular and even, and that the exudate is absorbed, or, in 
the other case, the serous surfaces rendered smooth. 

The pain connected with the compression and rubbing due to 
the exudate would, of course, best be handled by morphin in J- to 
^-grain doses subcutaneously. If the irritation cause a cough 
heroin in ^-grain doses should be substituted for the morphin. 

The most important aid to promoting cardiac regularity is 
physiologic rest, and this is obtained by keeping the patient re- 
cumbent, with an ice bag over the chest. In applying such an ice 
bag it is well to remember that the rubber should not touch the 
bare skin, but that there should be a layer of cloth between. 
Neither should the whole weight of the bag of ice rest on the chest, 
but it should be supported by some sort of cradle above the pa- 
tient. The first application of ice to the chest usually gives some 
discomfort in nervous patients, and not until the lapse of about 
one half hour at least does the relief begin to appear. This treat- 
ment is usually sufficient to secure rhythmic cardiac action. Only 



258 DISEASES OF THE CIRCULATORY SYSTEM 

when we have cyanosis, small and rapid pulse, and the other signs 
of cardiac weakness do we really need to resort to cardiac 
stimulants. 

The drug that best serves to promote the smooth action of the 
heart is digitalis, given preferably subcutaneously in the form, for 
example, of Merck's German digitalin (dose one tenth to two 
grains) or by the mouth in the form of the tincture, twenty to 
thirty drops every four hours. As soon as the pulse rate is within 
normal bounds and the heart action rhythmic, the drug should be 
stopped. The internal administration of digitalis is so nauseant 
that it is liable to upset the stomach, already badly affected by the 
disturbed circulation. 

The drug best adapted to promote the absorption of the exu- 
date is an iodid, which, as noted elsewhere, promotes catabolism, 
thus hastening the breaking down and absorption of pathological 
formations. It should be given in five- to ten-grain doses (in satu- 
rated solution or in a carminative vehicle) three times a day. Fi- 
brolysin, to absorb the adhesions, may also be tried after the active 
inflammation has somewhat subsided, but its effects are appar- 
ently as uncertain as those of the iodids. It is given subcutane- 
ously in doses of 2.23 c.c. on alternate days. 

The pericardial exudate is frequently great enough to demand 
the operative removal of the fluid. Even a moderate amount may 
demand such removal if the circulatory compensation be broken. 
The use of thymol (Gussenbauer, 1884) and other drugs for re- 
moval of such large exudates has only an historical interest, and 
we now place our dependence entirely upon mechanical inter- 
ference. The normal pressure in the pericardium is — 3 to — 5, 
measured in mm. of mercury ; therefore it requires only a few hun- 
dred centimeters of fluid within the pericardium to make the intra- 
pericardial pressure positive, unless, indeed, the sac have lost its 
elasticity; for, after all, it is the tension rather than the amount 
that counts. 

Purulent exudates require, of course, the resection (under 
ether) of the ribs and a wide opening of the sac, with consequent 
irrigation. Making a trapdoor of the fourth or fifth costal car- 
tilage with the muscular tissue in the third intercostal space as a 
hinge, thus enabling one to push aside the internal mammary 
artery, is the best procedure. After cautiously opening the sac, 



THE HEART 



259 



it should be irrigated with warm saline or boric-acid solution. This 
irrigation may need frequent repetition. 

The technic of pericardial paracentesis varies but slightly from 
that used in draining the pleural sacs. A preliminary puncture 
with a hypodermic needle should always be made. Such a punc- 
ture should be made with the smallest possible trocar or needle, in 
order to injure the heart as little as possible. It is advisable to 
make a vertical incision through the skin along the left margin of 
the sternum in order to be freed, as nearly as possible, while mak- 
ing the puncture, from the motion of the chest wall. 

In choosing the point for inserting the needle, one should bear 
in mind that the internal mammary artery is between 2 and 40 mm. 
from the left margin of the sternum; one should therefore punc- 
ture the thoracic wall 
either against the ster- 
num or at least an inch 
away from it, especially 
in the fifth intercostal 
space. Furthermore, the 
pleura must be avoided. 
The thoracic wall is 20 
mm. thick over the 
heart. The accompany- 
ing illustration shows 
where the margin of the 
pleura may be found. 
From this it may be 
seen that the best place 
for inserting the needle 
is the fifth intercostal 
space close to the ster- 
num, and that the point 
of the needle should be 
sternum. 

The dangers of the operation are: (1) Injuries to the lung and 
pleura and their infection from the needle; (2) air has sometimes 
been let into the sac (this, however, is not apt to happen with the 
apparatus shown in our discussion of thoracocentesis) ; (3) sud- 
den deaths have occurred, but it is questionable whether they can 




Fig. 43. — The Various Limits of the Left 
Pleura. 

directed toward the right under the 



260 DISEASES OF THE CIRCULATORY SYSTEM 

be charged to the operation. At any rate, they would probably be 
due to the nervous shock rather than to mechanical interference 
with the cardiac action; (4) the heart has been injured by too 
quick or careless insertion of the needle. When this happens it is 
usually the right ventricle that is injured; fortunately such in- 
juries are rarely fatal. 

The quantity removed has varied from zero to 3,500 c.c. West's 
table shows the results in eighty-four cases, as follows: 



150 c.c. 


-300 


-450 


-600 


-900 


-1200 


-1500 


More than 1500 


13 cases 


15 


9 


8 


12 


11 


4 


11 cases 



The success of the operation is hard to estimate, because the 
disease causing the exudate is usually fatal of itself, and the re- 
moval of the exudate simply eases the heart action and makes the 
patient more comfortable; nevertheless even this result is worth 
the effort. 

For the insomnia of pericarditis morphin (or, in compensated 
cases, a bromid) is the proper hypnotic. 

For the rheumatism or other infection underlying the pericar- 
ditis we proceed as if the pericarditis were not present. Fre- 
quently, however, we cannot discover the primary disorder. In 
such case we would advocate giving hexamethylenamin to render 
the body fluids as sterile as possible; dose, five grains three times 
a day. 



Myocarditis 

When the heart muscle is attacked the first indication must be 
to relieve the heart of all extra work, therefore the patient is kept 
recumbent and absolutely at rest. Generally digitalis is used in 
this condition to keep the action of the heart as nearly regular as 
possible, and ice is applied externally to assist in securing this 
result. Some writers believe that a fatty degeneration of the 
heart is a contraindication for the use of digitalis, but others use 
it in all conditions demanding a slower and stronger ventricular 
contraction. 

It is very important in all these cases to diet the patients care- 



THE HEART 261 

fully in order that there be no disturbance of the stomach, causing 
it to press against the heart and thus mechanically hinder its ac- 
tion. Moreover, any other irritation of the splanchnic and vagus 
nerves interferes with the heart action. The principles upon which 
such dieting proceeds are: (1) The amount of fluid ingested should 
be reduced to the minimum; (2) the heavy meal (if such a meal 
be necessary) should be in the middle of the day; (3) the food 
should be simple and of but slight variety (not heterogeneous), and 
of the more nutritious sort; (4) as little of chlorin as possible 
should be given in the food. The " Karel cur," which consists 
essentially of rest in bed and 200 c.c. of milk five times a day, is a 
type of this treatment, in which the food, though fluid, furnishes 
the minimum amount of fluid necessary for daily consumption. 

If the myocarditis be due to the invasion of the muscle by 
microorganisms, then antiseptic drugs, such as salol, hexamethyl- 
enamin, guaiacol, and the like are used in the effort to render the 
blood as poor a medium as possible for the growth of these bacteria. 

Some therapeutists use collargol, which is a colloidal silver. 
It is a black crystalline substance, soluble in fifty parts of water. It 
should be used intravenously, or, if the infection is not very severe, 
it may be used in the form of a fifteen-per-cent ointment by in- 
unction. Its success is very doubtful. 

"When the condition is a chronic one the iodids are given in 
order to assist in the building of new and better muscle by stimu- 
lating the general bodily metabolism. 

Sometimes the physician contents himself with a routine pre- 
scription like the following, which, in our judgment, is of question- 
able value, but is often used where we, on the other hand, should 
prefer to put our reliance upon something more specifically di- 
rected toward affecting the varying condition of the patient from 
day to day. Thus on one day we might have to use diuretin to 
stimulate the diuresis, on another pay all our attention to overcom- 
ing digestive disturbances, etc. ; but because there is considerable 
argument for having a routine prescription, we quote it, as follows : 

T£ Pulv. fol. digital, titr. 

Pulv. bulb, scillae aa 1.0 

Rad. et ext. gentian q. s. ad pil. no. XXX. 
Sig. One t. i. d. 



262 DISEASES OF THE CIRCULATORY SYSTEM 

Endocarditis 

If it is the endocardium which is attacked, we have either a 
leakage in the valves or the formation of vegetations within the 
cavity, or both. Here, also, the first indication is absolute rest with 
the application of cold, by means of ice bags, to the chest ; and also 
a very careful attention to the gastrointestinal tract. Thus small 
doses (three grains in broken doses) of calomel given daily and 
the occasional use of mineral waters will be found of value in all 
these cardiac conditions. Digitalis is the first thought in cardiac 
disease involving arrhythmia, and it may be given by the mouth 
either as a tincture in twenty- to thirty-drop doses three times a 
day or hypodermically as Merck's German digitalin in one-tenth- 
to two-grain dosage. 

In severe cases of infective endocarditis the use of vaccination 
has been found worthy of trial. The best cultures from which to 
make the vaccines are made from the patient's blood. The twenty- 
four-hour-old cultures are washed down and killed by heat and 
then injected subcutaneously in the dosage of one half million 
germs or over, according to the patient's resistance. Careful at- 
tention must be given to the patient's reaction and no second dose 
given until the patient's condition warrants it; that is, until the 
' ' positive phase ' ' of the reaction is present. This is usually indi- 
cated by an improvement in the pulse, temperature, and general 
feeling of the patient, and occurs from two to five days after the 
injection of the vaccine. 

In these cases where streptococci may be found in the blood- 
stream the use of polyvalent antistreptococcic serum is warranted 
(see notes on remedies). 

When patients suffering from leaking valves have overcome the 
initial loss of circulatory equilibrium, it is a good therapeutic point 
to try to strengthen these valves by very carefully graduated exer- 
cises and passive movements (Schott or Nauheim treatment). The 
beginning treatment of this type is by the use of carbonic-acid 
baths, which, through the skin stimulation, seem to have a very 
good effect on the heart muscle. They are ordinarily made by dis- 
solving to each 10 gallons of water at 95° F. 3 pounds of sodium 
chlorid, 4J ounces of calcium chlorid, 2 ounces of soda bicarbonate, 
and 3 ounces of commercial hydrochloric acid. The first bath 



THE HEART 



263 



should usually last only five minutes, but the length of time is 
increased daily. The temperature of the first bath is, as indicated, 
at 90° to 95° F. The temperature of succeeding baths is gradu- 
ally reduced from day to day until 50° F. is reached. The patient 
is, of course, lifted on a sheet into the bath tub and out of it, in 
order that there be no exertion on his part. Rock-salt baths (2J 
to 7-| pounds of rock salt in 75 gallons of water) may be substi- 
tuted for the carbonic-acid baths in some cases. Here the tem- 
perature begins at 95° F. and the bath lasts about ten minutes. 

For ambulant patients suffering from valvular lesions con- 
siderable attention should be given to the character of the under- 
wear. The loosely woven linen mesh seems to be a favorite in our 
changeable climate, and the woolen better adapted to the moister 
(but more equable) climate of England and the Continent. 

The diet needs to be carefully chosen to prevent fermentation 
and dilatation of the stomach, hence starchy foods should be re- 
duced to a minimum and carefully dextrinized (triscuit, shredded- 
wheat biscuit, etc.). 

Following the carbonic-acid baths, resistance movements are valu- 
able in gradually increasing the cardiac power. Thus the patient lies 
with his legs straight out and tries to keep them so while the physi- 
cian either lifts the leg or bends the knee, putting but little effort 
into the movement at first, but gradually increasing the strength 
applied to different muscles and joints from day to day. These 
two things are practically the essence of the Nauheim treatment. 

The following pulse tracings show the effect of the Nauheim 
treatment by means of carbonic-acid bath and resistance exercises. 
Figures e to I show the consistent development of one patient. 
(Quoted from Th. Schott, Herzkrankheiten, 1890.) 



(a) Before the bath : Pulse rate 94, blood pressure 120. 



(6) After a carbonic-acid bath at 88° F. lasting 15 minutes: Pulse rate 72, pressure 140. 
(c) Tracing made before exercise: Pulse rate 80, blood pressure 125, 



264 DISEASES OF THE CIRCULATORY SYSTEM 




(d) After 30 minutes of resistance movements: Pulse rate 95, pressure 160. 
(e) Tracing made before any treatment: Pulse rate over 150, blood pressure 82. 




(/) Tracing made on the next day after a 1% carbonic-acid bath at 92° F. lasting 10 

minutes. 

(g) Same patient, after 8 days of baths: Rate 144, pressure 95. 

J\AAJUU\A^ 

(h) Same on 9th day after 3^ hour of resistance exercise: Pressure 110. 
00 Same on 14th day: Rate 108, pressure 115. 




0*) After 3 weeks: Rate 108, pressure 125. 




(k) Before resistance exercise: Rate 102, pressure 130. 
(l) After the resistance exercise: Rate 92, pressure 145 



THE HEART 265 

Illustrative Case Histories (quoted from Hofmann) : 

Case I. — Tradesman, fifty-two years old, healthy until May, 1907. 
Attacked then with dyspnea and pains in the chest, which became worse 
when he walked and at that time were specially noticeable between the 
shoulders. Since the patient was a heavy eater and moderate drinker 
the first thing done was to cut down his rations one half and to forbid 
alcohol; then digitalis was prescribed. This improved his condition, 
but the middle of May, 1908, the same symptoms recurred because the 
patient had stopped following the prescriptions. The legs swelled to 
the knees, the abdomen was distended, and the shortness of breath 
reached the stage of dyspnea when the patient attempted to go upstairs. 
At this time the following status was found: well nourished, successful 
looking man 168 cm. tall and 85 kg. weight. Light cyanosis, especially 
on undressing or other exertion. Lungs sound but with scattered rales 
over the bronchi. Cardiac dullness reaches the middle of sternum, tones 
pure, but muffled. Pulse 120, small, easily compressed. Liver reaches 7 
cm. beyond ribs, abdomen distended, ascites present. Edema reaches 
from feet to middle of abdomen. Urine medium concentration and free 
from albumen and sugar. Diagnosis: myocarditis. Treatment: The 
Karel treatment was prescribed (bed rest, 200 c.c. milk three times a 
day) which in spite of his abhorrence of milk the patient carried out. 
On no day did the patient drink the prescribed amount of fluid, still 
the amount of urine on the second day reached 2,000 c.c. On the fourth 
day the amount was even greater, and the edema and ascites had dis- 
appeared. The liver was now normal in size, and the pulse had fallen 
to 90. After seven days the patient felt so well that he left his bed and 
went to work. Loss of weight, 11 kg. 

In seven weeks he had a relapse with dyspnea, edema, and ascites, 
as before the " Karel cur," which the patient refused to take again. 
A diet in which but little salt was found was ordered — coffee with 
milk, meat, bread, butter, potatoes, fruit, without salt. This diet brought 
about just as good a result as the milk treatment and in just as short 
a time. This, with the following prescription, has kept the patient in 
good order since that time : 

^ Pulv. fol. digital titr. 

Pulv. bulb, scillse aa 1.0 

Ext. strychni 0.3 

Pad. et ext. gent. q. s. ad pil XXX. 
Sig. One pill t. i. d. 

Case II. — Engineer, fifty years old, always healthy, suffered from light 
attack of diabetes in 1904 which did not affect his general health. Pulse 



266 DISEASES OF THE CIRCULATORY SYSTEM 

was even then small and rapid (100). In June, 1907, he became short 
of breath and had pains which radiated into left arm. Improved under 
treatment of bed rest and digitalis. The patient had a liking for well- 
salted food, and would add 15 to 20 grams of salt to his already well-salted 
food. At that time his status was : well nourished, 160 cm. tall, weigh- 
ing 84.5 kg. Rather pronounced cyanosis, which increased upon move- 
ment. Lungs sound. Cardiac dullness extended to right. Systolic mur- 
mur at apex, which is pronounced on movement but disappears when 
patient is quiet. Liver reaches navel. Abdomen distended. Ascites 
plainly evident. Edema of legs, scrotum, and belly wall. Urine shows 
trace of sugar and albumen, no casts, a few white corpuscles. Treat- 
ment : " Karel cur " : one liter of milk daily in five portions, which are 
not all drunk. In three days increased diuresis had caused the edema 
and ascites to disappear. General feeling excellent. Then a mixed diet, 
poor in salt, was ordered and patient permitted to leave his bed for 
short periods. In fourteen days patient was cured, for there was no 
trace of circulatory disturbance. Pulse 90; cardiac tones pure; no 
edema; no shortness of breath. Loss of weight 12.5 kg. 



The Heart in Constitutional Diseases 

When the heart seems to be about to collapse in the course of 
different constitutional diseases, such as typhoid and pneumonia, 
different drugs are used, according to the character of the primary 
disease. Thus in typhoid fever, because the type of the poison 
is convulsant or similar to strychnin in its action, probably the 
most satisfactory medication for the circulation is camphor, and 
this, when used in the form of an aseptic neutral solution (ten per 
cent in olive oil) in dosage of 6 c.c. pro die, proves to be efficient 
not only in giving a more even circulation, getting rid of a good 
deal of dicrotism, but also in quieting the mind and relieving much 
of the nervous twitching. In pneumonia digitalis will be found 
the best drug to be used (as indicated in the discussion of that 
disease) in rather large quantities for a few days. If the disease 
be diphtheria or some disorder that relaxes the blood vessels and 
dilates the capillaries, then caffein may be better indicated than 
digitalis, because this acts more upon the vasomotor system than 
it does upon the heart muscle itself. This is usually given in the 
form of the citrate in doses of from two to eight grains. 

In nephritis, either acute or chronic, the heart is always af- 



THE HEART 267 

fected. If the nephritis be toxic, then from the very beginning 
the heart would suffer from it. If the nephritis be simply one of 
the interstitial character, the heart does not show any result of the 
strain until later in the disease. Probably the best drug to steady 
the action of the heart and help increase the amount of excretion 
through the kidneys is one of the double salts of theobromin. For 
instance, diuretin in doses of one gram three times a day will 
prove very efficient in giving not only something of the caffein 
action of the heart, but also to increase gradually the diuresis. Of 
course digitalis may be added to the diuretin, and one in that way 
gets a more certain -effect upon the heart muscle, as well as the 
control of the vasomotor system. 

In adolescence the heart frequently does not grow as rapidly 
as does the remainder of the body, and therefore is relatively in- 
sufficient. In such conditions, the principle of resistance exercises 
should be adopted and the patient gone over thoroughly to ascer- 
tain what exercises are the most particularly indicated, then should 
be given exercises, diets, and baths that will from day to day 
stimulate the heart to increased activity and growth. More can 
be hoped from this sort of hygienic treatment than from the use 
of drugs, although digitalis is often used in these conditions. 

The following exercises (from Poynton) illustrate the above 
statements regarding resistance movements: 

Schott Movements. — 1. Arms extended in front of the body at the 
level of the shoulders and palms touching. The patient slowly moves 
them outward until in a line with one another against the gentle re- 
sistance of the operator. This done, they are slowly brought back to the 
original position. 

2. Arms dependent. Patient flexes forearm until hand touches shoul- 
der, and then returns to original position. One forearm is flexed at a 
time. 

3. Arms dependent, then slowly swept round in the arc of a circle 
until the thumbs touch above the head; then back again. 

4. Arms dependent, hands meeting over abdomen, and the first 
phalanges pressed together against one another. In this position the 
arms are raised to the level of the head, and then returned to the same 
position. 

5. Arms at attention, then slowly raised forward to the vertical po- 
sition and back again. 

6. The same movements as No. 1 with the fist clenched. 



268 DISEASES OF THE CIRCULATORY SYSTEM 

7. The same as No. 2, but with the fist clenched. 

8. Flexion of the trunk to a right angle without flexion of the knees, 
and return to the original position. 

9. In the erect 'position rotate trunk without moving the feet, first 
to one side, then to the other, then back to original position. The op- 
erator will place one hand in front of the advancing shoulder, the other 
behind the retreating one. 

10. In the erect position, flex the trunk laterally, first to one side, 
then to the other, and return. 

11. Erect position. Hands dependent, arms extended. Make a com- 
plete revolution of first one arm, then the other. 

12. Erect position. Arms extended, hands against thighs. Move up- 
ward and backward without flexion of the trunk, and return to the 
original position. 

13. Erect position. Stand supported by hand on the chair. Flex 
thigh to abdomen, and back again. 

14. Same position. Keep the leg stiff, and bend the whole limb first 
forward, and then backward. 

15. Erect position. Flex and extend leg on thigh. 

16. Erect position. Abduction and adduction of the lower ex- 
tremity. 

17. Erect position. Arms abducted to the horizontal line, rotated 
forward and backward to their extreme limits. 

18. Flexion and extension of the wrist. 

19. Flexion and extension of the ankle. 

All these movements are made slowly against the slight resistance of 
a skilled assistant. The movement is repeated according to the judg- 
ment of the operator, and rest is allowed after finishing each group. 
The condition of the patient is carefully watched and the exercises 
varied accordingly. 

Special Symptoms. — In heart disease there are many symptoms 
due to the disturbed circulation, but symptoms that do not call for 
heart tonics per se. Thus insomnia, due to the inequality of the 
blood supply to the brain, should be treated with the bromids 
rather than the cerebral depressants. Fifteen to twenty grains of 
sodium bromid should be given in hot milk two hours before 
bedtime. 

The dyspnea is best treated with small doses of the opiates until 
one can restore the equilibrium of the circulation. 

The epigastric pain is best handled by the application of cold, 



THE BLOOD VESSELS 260 

either by means of the ice bag or the coil through which cold water 
is flowing. 

In other words, these symptoms should be treated symptomat- 
ically until one can restore the physiologic tone to the circulation 
by means of rest and vasomotor tonics. 



THE BLOOD VESSELS 

Arteriosclerosis 

The most that can be hoped in this condition is to stop the 
progress of the disorder and relieve the symptoms. A restitutio 
ad integrum is still beyond our therapy, though we still dream of 
fibrin and scar-tissue dissolving drugs which shall rid the vessels 
of their inelasticity and friability. The disease is due to strain 
and overwork or to such constitutional diseases as syphilis, hence 
any measures to check the progress of the disorder must call for a 
change in the habits of life of the patient, as well as the use of 
positive influences to bring about the necessary tissue changes. The 
symptoms resulting from arteriosclerosis are the headache due to 
the inabilty of the vessels to accommodate themselves to the vary- 
ing conditions demanding dilation and constriction; nephritis, 
which almost always results from arteriosclerosis; the heart be- 
comes degenerated and the patient suffers attacks of angina pec- 
toris, and finally the scene is usually closed by the cerebral vessels 
breaking down and the patient suffering a fatal stroke of apoplexy. 

In order to break down the pathological formations in the walls 
of the blood vessels, potassium iodid is usually exhibited. This is 
particularly efficient where the arteriosclerosis is due to syphilis, 
and in such a case should be given in immense doses. In ordinary 
cases, however, ten to fifteen drops of the saturated solution are 
given three times a day, and with little perceptible result. 

The high blood pressure existing in arteriosclerosis can some- 
times be beneficially influenced for short periods of time by the 
use of sodium nitrite (five grains in solution three times a day). 
However, the system soon becomes immune to this drug and the 
blood pressure returns to its former state. 

Therefore one has the best prospects of success in such condi- 
tions by putting the patient into an institution where hydrotherapy 



270 DISEASES OF THE CIRCULATORY SYSTEM 

may be given in addition to the drug medication. This life, since it 
combines massage, the application of electricity, and very careful 
oversight of diet and exercises, will in a great many cases prove 
sufficient to check the progress of the disorder. Naturally, any 
such course of treatment must be carried on for several months in 
order to accomplish any results. 

For patients who cannot afford to go to a sanatorium, one must 
prescribe relief from overwork, additional sleep, additional out-of- 
door exercise, hot tub baths, Turkish baths, restricted diet, etc., as 
the environment may permit. The hours of work must be so 
rigorously cut down that the patient will awake refreshed in the 
morning. At the beginning of the treatment, a nap or siesta after 
the noon meal will be needed. The out-of-door exercise should 
include something more than walking. For, while walking over 
the country road is good, walking over the pavements is bad. Golf, 
of course, is excellent. Driving and riding where possible are to 
be encouraged. Gardening is helpful. Tennis is usually too vigor- 
ous. The diet must be restricted to what the patient really needs 
and what he can easily digest. Prolonged mastication of the food 
and the use of plenty of water between meals will assist in the 
utilization of a suitable diet. 

The nephritis and other symptoms resulting from the arterio- 
sclerosis are to be treated symptomatically. Thus in nephritis the 
salt-free diet and the hot-air baths will be the most potent remedies. 
The former is obtained by using milk and cream as the diet (four 
to six ounces every two or three hours), and the latter can be 
arranged for even at home by making a cabinet out of a bed, as 
has been described elsewhere. 

The angina pectoris requires the administration of nitroglyc- 
erin and atropin. The retrosternal pain requires similar treat- 
ment. All such pains, however, demand the adoption of hygienic 
and dietary measures to reduce the strain upon the heart and 
blood vessels. The nitroglycerin (y^-g- gr.) and atropin (y^j- gr.) 
may be given together subcutaneously. 

Apoplexy 

Cerebral hemorrhage usually occurs as a final result of arterio- 
sclerosis, although it may occur without any arteriosclerotic condi- 






THE BLOOD VESSELS 271 

tion. The therapeutic indication, of course, is for a line of treat- 
ment that shall stop the exudation of blood into the brain and 
that shall also promote the absorption of the blood already exuded. 
The first is usually obtained by putting the patient in bed and 
packing the head in ice. The use of heat to the feet at the same 
time may be advantageous, in that it tends to reduce the intra- 
cranial blood pressure. The promotion of absorption is to be 
looked for through a general stimulation of all the metabolic 
processes. Thus the internal administration of the iodids will tend 
here, as in the case of other exudates, to cause the absorption of 
the material lying outside of the vessel walls ; hence a prescription 
for a man suffering from apoplexy (but without pain or other dis- 
comfort) would include nux vomica, an iodid, and a cathartic, as, 
for instance, the following: 

1$ Tct. nucis vomica? 15.0 c.c. 

Potassii iodidi 10.0 grams. 

Ext. fl. cascarae sag 5.0 c.c. 

Elixiris gentian, glycerinati (N. F.) . . . . 200.0 c.c. 
Sig. One dessertspoonful three times a day. 

The use of massage and oil rubs should not be neglected whenever 
it is practicable to give them. 

Varicose Veins 

Probably the best treatment for chronic varicosities is surgical, 
because in such conditions the venous walls have lost their power 
of recuperation and constriction and had better be removed at 
once. The apparent reduction of the varicosities produced by the 
application of elastic bandages and similar supports is at best only 
temporary. It should be resorted to, therefore, only when the 
more radical treatment by the resection of the dilated vessels is 
impracticable. 

Beginning varicosities can be helped by using digitalis to con- 
strict the vessels as well as stimulate the heart. Whether or not 
it would be possible to overcome a congenital tendency to varicosity 
by such medication is impossible to say. But such varicosities as 
are induced by constricting bands and prolonged standing on the 
feet could be warded off if the bands (garters, for instance) be 
19 



272 DISEASES OF THE CIRCULATORY SYSTEM 

removed and the patient be given employment less exhausting. 
In such cases the use of digitalis or of adrenalin (intravenously) 
should be tried. The insomnia in such cases (due to the hyperemia 
of the brain when the patient lies down) can be helped by using 
digitalis to constrict the blood vessels. Inasmuch as digitalis is 
slow of action, one should give the drug in the afternoon at, say, 
four o'clock, unless one use the quicker acting digitalin, or digalen, 
hypodermically. 

Varicose Ulcers 

These are usually due to the flooding of the tissues with the 
exudate from the neighboring varicose veins. Therefore the first 
indication for their successful treatment is the relief of the vari- 
cosity, or at least the draining of the tissues of the superabundant 
supply of serum. This indication is interpreted by a German 
physician, Schweninger, to mean the cutting of trenches around 
about the ulcer, thus shutting it off from any direct blood supply. 
Ordinarily, however, this draining of the tissues is accomplished 
by the use of tight bandages combined with a stimulant cleaning 
off of the ulcer surface. The irritation accompanying ulcers may 
be relieved by the application of zinc oxid ointment (twenty per 
cent). 

The infection of the floor of the ulcer is removed by rubbing it 
with gauze wrung out in 1 : 1,000 bichlorid-of-mercury solution. 
After the tissues dry, powdered iodoform is sprinkled on the raw 
surfaces and protective bandages applied. 

Relaxed Vessels 

This condition forms a menace to the general health, particu- 
larly when the vessels of the portal circulation are affected. In 
such cases it results in indigestion, headaches, cold extremities, 
insomnia, and a general feeling of discomfort in and about the 
abdominal cavity. In fact, some writers believe that most cases 
of " the blues " are due to portal congestion. 

The treatment should proceed along two lines: (1) The pa- 
tient's life should so be regulated that all the abdominal muscles 
are stimulated into activity, and (2) the circulation of the skin and 
in the extremities should be stimulated so that the blood is kept 



THE BLOOD VESSELS 273 

from stagnating in the portal tract. Both of these things are ac- 
complished by deep breathing, massage over the epigastrium and 
abdomen, and by bending exercises (Abrams). 

The general outline of life given above for beginning arterio- 
sclerosis would apply here, except that here the exercise may be 
much more vigorous and the use of cold baths more often indi- 
cated than hot ones. In fact, the morning rub with cold water and 
exercises so vigorous that the perspiration rolls out are the best 
procedures. 

There is also the internal line of treatment. The blood pressure 
in the splanchnic area may be increased quite materially by the 
use of digitalin (the alkaloid) hypodermically. Ergotoxin, or even 
the crude drug when prepared for subcutaneous use, will prove 
useful. Even when the fluid extract of ergot has been given by the 
mouth it has yielded results worth while. Adrenalin used intra- 
venously or intramuscularly would have a less lasting effect and 
therefore would not be as useful here as the subcutaneous injection 
of digitalin or ergot. Styptol (or stypticin) in three-fourth-grain 
pills (three or four times a day) should also be thought of, but 
since it has a tendency to produce a contraction of the capillary 
walls alone where a more general contraction would be more bene- 
ficial, it is not as efficient as one of the above. Camphor used 
hypodermically as a neutral oil, ten to twelve per cent, or even by 
the mouth, would increase the blood pressure in the splanchnic 
area, and would therefore be decidedly valuable. The effect of 
caffein would be less, but it might be used in combination with 
the other drugs for its blood-pressure-raising effect. It should be 
given as caffein citrate in doses from two to eight grains. 

The use of the alternating hot and cold douches and fomenta- 
tions would be helpful in any systematic treatment of this disorder. 
In the use of the hot and cold fomentations, a cloth is wrung out 
in water as hot as can be borne and laid over the abdominal area, 
or along the spine, and after about three minutes the cloth is re- 
moved and ice is rubbed over the same area for perhaps a half 
minute ; then a fresh hot cloth is applied. This treatment is usually 
somewhat safer if applied to the back than the front of the trunk, 
because when applied to the abdomen the shock to the system is 
so great that it may cause trouble if the patient be not fairly 
robust. 



274 DISEASES OF THE CIRCULATORY SYSTEM 



In applying the douche, the patient is sprayed with a current 
of water at, say, 60° to 70° F., and then as soon as he has reacted 
to it, with one at 100° to 120° F. The force of the current and the 
heat of the water are both regulated according to the resistance 
of each patient. 

Capillary Hemorrhage 

Capillary hemorrhage may be due either to the relaxation of the 
capillary wall or to the lack of coagulability of the blood itself. In 
the first type, astringents or constrictors are called for; in the 
second, coagulants. In detail, the treatment is the following : 

When it can be reached locally, as in the case of uterine or nasal 
hemorrhage, hemorrhage may be treated by the application of styp- 
tics. Adrenalin applied locally in 1 : 1,000 solution is, of course, 
the least damaging to the tissues, and in ordinary conditions will 
prove sufficient. Should it not prove sufficient, resort may be had 
to the iron salts which produce a searing of the superficial tissues. 
Thus, the liquor ferri chloridi, a thirty-eight-per-cent solution of 
the salt, will be found one of the strongest styptics, but should be 
applied very carefully, because it is corrosive and will injure any 
tissues or material touched. It should be applied on a wooden 
applicator. 

In the nasal hemorrhage of pernicious anemia the liquor ferri 
chloridi has proven the most efficient. The bleeding points should 
be touched with the solution and then the entire cavity packed with 
absorbent cotton. 

In the uterine hemorrhage of endometritis, thorough curettage 
seems to be the only efficient treatment. The intra-uterine appli- 
cation of styptics is merely temporary, and yet very painful. 

In the hemorrhage of icterus and similar states, the calcium 
salts have long been used, but with doubtful effect. Addis has 
shown that calcium does not increase the coagulability of the blood 
(British Medical Journal, April 24, 1909), yet we find many cases 
in which the coagulation time is reduced by the administration of 
large doses of calcium salts. The best results are obtained when 
we use a nucleo-protein such as thyroid extract with the calcium. 
Thus we would give 15 grains of calcium lactate and 3 grains of 
thyroid extract three times a day — the former after meals and the 
latter on an empty stomach. 



THE BLOOD VESSELS 275 

The subcutaneous injection of gelatin has been used for many 
years in cases of capillary hemorrhage, but the difficulty of freeing 
the gelatin from tetanus bacilli has depressed the ardor of those 
who would otherwise use it. On the other hand, the thoroughly 
sterilized preparations of gelatin have generally lost their styptic 
effect, and for that reason are equally useless. 

The best method of preparing gelatin in order to render it 
germ free and yet retain its styptic power is perhaps to take 4 to 
5 grams of the best white gelatin and dissolve it in 200 c.c. of warm, 
sterile seven-tenths-per-cent solution of sodium chlorid. This solu- 
tion is thereupon sterilized for four successive days, a half hour 
each day in steam vapor at 100° C. The solution must be com- 
pletely clear. In case it is not it should be boiled up with some 
solution of egg albumen and filtered until it is completely clear. 
The sterile solution should be kept in bottles with glass stoppers, 
sealed with glazed paper or rubber caps. Before using the bottles 
containing the solution should be warmed to the proper tem- 
perature. 

For injection, one uses one of the larger syringes (25 c.c.) . The 
fluid is injected either in the glutei or between the shoulder blades 
very slowly and in quantities of 150 to 200 c.c. The best method 
is to insert the needle, and when no blood shows, attach the syringe 
and slowly drive in the fluid gelatin. The syringe is then detached 
from the needle, refilled, and its contents injected, and so on, until 
the total quantity required has been put within the subcutaneous 
tissue. There is considerable pain connected with the operation, 
for which, of course, one should apply heat, either with cloths 
wrung out of hot water, or the thermophore. The injections may 
be repeated daily until one is sure that the hemorrhage has ceased. 

Gelatin can also be injected directly into bleeding hollow or- 
gans, such as the stomach and bladder, or into the joints, and good 
effects have been seen from it. 



Purpura 

Purpura is probably due to changes in the blood itself, brought 
about by toxins and hemolysins. Thus we find purpura in cases of 
icterus of long standing. Here the hemorrhage is due to the action 
of the absorbed bile. Likewise we find purpura in severe strepto- 



276 DISEASES OF THE CIRCULATORY SYSTEM 

coccic infections. Hence the disease should not be looked npon as 
idiopathic and our treatment limited to the symptoms. On the 
contrary, it should be regarded as merely a symptom and the cause 
searched out and causal therapy instituted. 

The treatment of the symptom is by means of calcium and 
thyroid extract, as mentioned under capillary hemorrhage. 

The symptomatic treatment calls also for careful dieting, so as 
to keep the bowels active and also so as to secure the maximum 
efficiency of the food values ingested. Thus milk, eggs, fruit juices, 
rare steak, carefully dried toasts, etc., should be prescribed and 
chosen. Cathartics must be avoided, because of their liability to set 
up intestinal hemorrhage. 

Hemophilia 

Hemophilia is, of course, treated symptomatically. Adrenalin, 
either locally or intravenously, according to whether the bleeding 
is local or general, should be our first thought. The injection or 
application of gelatin may also be employed with success. Thus 
bleeding from the bowel would be best handled with gelatin ene- 
mata. The essential element seems to be pressure or constriction 
at the point of hemorrhage, therefore the use of the corrosive 
styptics seems needlessly destructive. 

Scurvy 

Scurvy seems to be due to the deprivation of the body fluids 
of elements supplied by citric acid and uncooked albumen. Hence 
the treatment requires that the patient be kept absolutely quiet 
(children may be packed in cotton) and the diet arranged to sup- 
ply the missing elements. Orange juice, lemon juice, fresh milk, 
raw vegetables, and beef juice should be employed in such form 
and quantity as is best taken by the individual patient's stomach. 

The mouth must be cleansed frequently and freed from infec- 
tion by the use of hydrogen peroxid and other antiseptics (see 
Stomatitis). The anemia may call for iron — or at least a diet rich 
in beef. Rectal enemata are best to keep the intestines open, and 
even these must be gently given. Most cases get well when given 
the appropriate care and diet without the administration of special 
drugs. 



THE BLOOD 277 

THE BLOOD 

Primary Anemia 

This pathological condition demands first of all some influence 
that shall stimulate the blood-building organs to throw out into the 
blood stream an increased supply of hemoglobin or blood corpus- 
cles. To make this stimulation most successful, there should be an 
attempt made to ascertain the cause of the condition, and if this 
consists in some fault in the mode of living, it should at once be 
corrected. If it is due, as is frequently the case, to systemic intoxi- 
cation, or to the presence of intestinal parasites, or the loss of blood 
from intestinal ulcers, then the treatment necessary for the cor- 
rection of the causal condition should at once be instituted. Con- 
sequently no case of primary anemia should be considered idio- 
pathic until all the means of diagnosis have been exhausted and 
the search should cover the gastric contents and feces as well as 
the blood and urine. 

Chlorosis. — In this condition there is a lack of hemoglobin or 
iron in the blood ; therefore the indication is for an increased sup- 
ply of iron in the diet. This is brought about in the simplest way 
by feeding the patient Blaud's mass or else saccharated ferrous 
carbonate in five-grain doses three times a day. Either one of 
these is superior to most of the other inorganic preparations in 
that it does not discolor the teeth or irritate the mucosa. Inasmuch 
as Blaud's mass is effective only when the carbonate is of the fer- 
rous rather than the ferric type, it is particularly important to 
have the preparation fresh and active. Blaud's pills should there- 
fore be freshly made for each prescription. Nowadays the follow- 
ing prescription would be just as satisfactory as the Blaud's pills: 

3J Ferri carbonatis saccharati 0.3 

M. f. capsula gelat. no. I. Da tales doses no. L. 
Sig. Take one capsule after each meal. 

"\Ylien chlorotic patients are suffering from hyperchlorhydria 
or other diseases of the intestinal tract, it may be necessary to give 
iron in the form of the organic salts. These are less corrosive and 
less irritant. Ferrous carbonate rarely ever, however, gives rise to 
gastric disturbances, but in some cases the albuminates will do the 



278 DISEASES OF THE CIRCULATORY SYSTEM 

work better and should then be chosen. As far as experimental 
research can demonstrate, the inorganic preparations are absorbed 
in the duodenum just as quickly as are the organic. Therefore on 
account of the increased cost of the organic form of preparation, 
the inorganic preparation should be used wherever applicable. 

The albuminates most used are Gude 's peptomangan, ovof errin, 
ferratin, etc. The former has become almost a patent medicine, so 
widely and thoroughly has it been advertised. On the subject of 
these preparations, we would quote the " New and Nonofficial 
Remedies of the American Medical Association, ' ' as follows : 

Organic Iron Preparations: The term, "organic iron" ("masked" 
or "nonionic" iron), is confined by modern usage to those organic com- 
pounds of iron which do not give the chemical tests of the metal (blue 
color with potassium ferrocyanid, blue-black color with hematoxylin, 
etc.) until the structure of the molecule has been destroyed by reagents. 
The resistance to this destruction varies greatly; some (such as hemo- 
globin) require incineration or the action of concentrated acids, while 
others give the iron tests after treatment with even fairly dilute acids. 
The organic compounds occurring naturally in animal and vegetable 
tissues (which are often termed " food irons ") belong generally to the 
more resistant class, while the iron of the synthetic preparations is usu- 
ally liberated fairly readily. This does not, however, constitute a sharp 
line of distinction between the two classes, nor is there any good evi- 
dence that they differ in therapeutic action. Until this difference is es- 
tablished all organic iron preparations, whatever their source, may be 
placed in a single class. It is evident, however, that an organic iron 
(chemically) which is destroyed by two-tenths-per-cent hydrochloric acid 
at the body temperature, cannot be classed as an organic iron in the 
therapeutic sense. It should also be emphasized that salts of iron (which 
gives the iron tests directly) are classed as organic iron whatever the 
acid radicle. True albuminates, peptonates, etc., of iron are therefore 
inorganic. 

Organic iron preparations are used to increase the hemoglobin in 
conditions of anemia. Bunge supposed that only organic iron could be 
absorbed and assimilated by the body, the reputed action of inorganic 
iron being altogether indirect, and due to its local effects on the ali- 
mentary canal. This theory was modified by Abderhalden to the effect 
that inorganic iron, while it could not be converted into hemoglobin, 
nevertheless stimulated the assimilation and conversion of organic iron. 
Later work, however (Tartaskowski), seems to prove conclusively that 
inorganic iron is assimilated and converted into hemoglobin, and is in 



THE BLOOD 279 

so far therapeutically fully equal to organic iron. Many authors, how- 
ever, still adhere to the theories of Bunge and Abderhalden. At all 
events a real difference exists between the organic and most of the 
inorganic preparations, namely, in the local irritant and astringent 
action of the latter, and the absence of these effects in the organic com- 
pounds. These actions may be desirable in some cases and undesirable 
in others. It should also be remembered that organic iron may often 
be administered in sufficient amount, and most economically, by select- 
ing a dietary rich in iron, such as red meats, egg yolks, green vegetables, 
whole wheat, etc. 

Pernicious Anemia. — In this type of primary anemia, it is the 
blood corpuscles that are attacked. They show an abnormal lia- 
bility to break down, and we find therefore a number of patholog- 
ical forms on every blood slide. If possible, the hemolytic toxin 
causing such a breakdown should be removed from the body. As 
we have indicated above, this toxin frequently originates in the 
intestinal canal; therefore a thorough cleansing of the intestines 
often brings about a rapid improvement in the condition of the 
patient. This cleansing should be given both by cathartics, with 
calomel as the preferable one, and also by colonic flushing with 
quinin bisulphate and normal salt solution. 

To stimulate the bone marrow, lymphatic glands and spleen 
(in short, the hematopoietic organs) to an increased activity in 
supplying corpuscles, arsenic is given in extremely heavy dosage 
(60 to 120 drops of Fowler's solution pro die). The prescription 
follows : 

5 Liquoris potassii arsenitis §ij. 

Sig. Begin with 10 drops in water three times a day, and in- 
crease by 1 drop each day until the dose is 20 drops. 

The X-ray applied to the long bones and over the spleen for five to 
ten minutes on alternate days will be found helpful. 

In this disease there come, no matter what type of medication 
is employed, periods of remission, and these should not be mistaken 
for cures. 

Whenever we use metals such as arsenic and iron for any 
length of time, we should keep in mind that they are excreted 



280 DISEASES OF THE CIRCULATORY SYSTEM 

chiefly through the mucous membrane of the large bowel. This 
renders necessary frequent colonic irrigation. If there are no pro- 
tozoa to be eliminated from the colon, simple saline solutions will 
be sufficient for such irrigations. 

Needless to say, the patient must keep his bed and avoid all 
work and worry while undergoing treatment. 

Secondary Anemia 

Here ordinarily the drain upon the system has been stopped 
before we begin treatment for the blood loss and one has only to 
deal with the resultant loss of blood substance. This loss is usually 
made good by giving iron in the form of Blaud's mass, or saccha- 
rated ferrous carbonate (5 grains three times a day). In some 
cases it is advantageously combined with jV grain of arsenic trioxid 
in order to secure a stimulation of the hematopoietic organs. The 
stomachics are indicated here to promote the absorption and stimu- 
lation of food. Naturally, one should be very careful while giving 
iron and similar astringent drugs to keep the peristalsis active by 
laxative food, mineral waters, etc. 

Leukemia 

In the leukemic diseases it is chiefly the number and forms of 
the white blood cells that show the progress of the disorder. Leu- 
kemia seems to be essentially a disease of the blood-building organs, 
therefore the treatment is similar to that employed in pernicious 
anemia, with more emphasis placed on the stimulation of general 
bodily functions. Since the disease seems to lie in the blood-build- 
ing organs, there is needed an increased supply of the blood ele- 
ments and constituents which these glands would normally furnish. 
Hence an attempt has been made to better the condition by giving 
thyroid extract, bone marrow, pituitary extract, etc. In some cases 
this has seemed successful. When exhibiting such glandular prod- 
ucts, the same principles should be followed as are laid down for 
giving of thyroid extract for hypothyroidism. Thus the extracts 
must be given under conditions which are the best for their absorp- 
tion from the duodenum (e. g., three hours after and one hour 
before eating). The dosage of the thyroid extract is ordinarily 
from 2 to 5 grains. Thus : 



THE BLOOD 281 

1$ Glandularum thyroidearum siccarum 0.2, 

M. f. capsula no. I. Da tales doses no. XX. 

Sig. One capsule on an empty stomach three times a day. 

Arsenic is freely used in leukemia either in the form of Fowler's 
solution, or hypodermically in the form of atoxyl, arsacetin, or 
soamin. The X-ray and the high-frequency current are also used 
to stimulate the bodily activities. In caring for the leukemic 
patient one should not forget the stimulant effect of cold douches, 
hot and cold fomentations to the spine, hot and cold sprays 
(Wechsel douche), etc. 

Trypanosomes 

These parasites inhabit the blood and lymph currents. Those 
of the African sleeping sickness seem to be found most constantly 
in the lymphatic glands. The medication up to date has not been 
successful. It has been found that the use of arsenic in extremely 
heavy doses is sufficient to inhibit the organisms and prevent their 
development, but it has been noted that in the case of " the sleep- 
ing sickness " in Africa that within six months after the discon- 
tinuance of the drug the disease sometimes recurs. 

Arsenic should, therefore, be used hypodermically in the form 
of sodium cacodylate, or atoxyl, or arsacetin. This permits the 
injection of relatively large quantities and thus keeps the system 
saturated. 

Ehrlich, of Frankfort, has been long engaged in the develop- 
ment of remedies to combat this condition. He has worked on the 
anilin dyes, because he has found them to inhibit the parasite with- 
out injuring particularly the host. The best that he has yet de- 
veloped is called the trypan red, but this drug changes temporarily 
the color of the skin and hair of the patient who is taking it, and is 
otherwise unpleasant. Hence the arsenic still seems the best treat- 
ment that we have for the condition. 

The injections are made subcutaneously on alternate days, 
using as much as the patient will bear ; for example, 25 minims of 
a ten-per-cent solution of atoxyl, or the same amount of a one-per- 
cent solution of arsacetin (i. e., begin with ^ grain (0.02) and 
increase to 10 grains (0.65)). 



CHAPTER VI 

DISOEDEES OF THE GENITO-UEINAEY SYSTEM 

FUNCTIONAL DISORDERS OF THE KIDNEY 

Uremia 

Uremia is the term given to the complex of symptoms re- 
sulting from the intoxication of the body by the waste products 
which normally are excreted by the kidneys. Hence the treat- 
ment of uremia is the treatment of symptoms rather than of a 
definite pathological condition, while the treatment of the under- 
lying lesion would be governed by the principles discussed under 
that head. 

The symptoms are those referable to a severe intoxication; 
therefore we find delirium, convulsions, or coma, according to the 
severity of the attack and the reaction of the patient. The symp- 
toms due to the disturbance of the digestive and circulatory 
symptoms are also pronounced, but may be looked upon as second- 
ary to the nervous symptoms. 

Hence the first need is to stimulate all the emunctories of the 
body and secure a freer elimination of the stored-up combustion 
products. For this purpose we use sweat baths for the skin and 
saline cathartics for the bowels. The former eliminates the more 
of the fluid, the latter of the solid elements, hence both should be 
used. 

The sweat baths may consist of hot packs (for technic, see In- 
dex), hot tub baths, or best of all, hot-air cabinet baths. The dry 
hot-air bath is to be preferred because it produces more profuse 
perspiration than the other types. 

The most satisfactory saline is magnesium sulphate. This 
should be used in tablespoonful doses every two hours until the 
bowels move freely. 
282 



FUNCTIONAL DISORDERS OF THE KIDNEY 283 

It will greatly aid in this process of elimination if normal salt 
solution be injected freely into the rectum or under the skin. 
For the former, the continuous inflow (according to Murphy's 
method), and for the latter 250 to 500 c.c. under the skin of the 
chest, flanks, or thighs furnish the best methods of procedure. 
Naturally more solution can be put into the body through the 
colon than through the skin, hence this is the procedure of choice. 
In very alarming conditions, a vein may be opened and 200 to 
500 c.c. of blood removed, and then a similar amount of warm 
sterile salt solution allowed to flow into the vein (intravenous 
infusion). (Be sure that the solution is a " normal " one. See 
Index.) 

The drug treatment must be aimed at the underlying lesion. In 
acute suppression of the urine, for example, one might use atropin 
to relax the renal tissues. In chronic nephritis one can sometimes 
see good results follow the administration of macerated kidney 
substance — either the fresh kidney chopped up fine and preserved 
in glycerin, or the commercial preparation called nephritin. The 
action of this substance is explained as antidotal to the toxins 
already absorbed. Of the fresh kidney substance one uses a tea- 
spoonful every four hours on an empty stomach. Of nephritin one 
uses five tablets every two hours. In many cases the subcutaneous 
injection of morphin gives surprisingly quick relief. This is purely 
empiric and symptomatic, and to be used only when more direct 
action is not possible. 

Anuria. — Of the conditions producing uremia, the total sup- 
pression of the urine (anuria) is the gravest. This may be due to 
changes in the nerve control or to pathological changes in the kid- 
ney. Hence, no effective causal treatment can be used until the 
diagnosis is complete. The symptomatic treatment is the same as 
for uremia from other causes — elimination and sedation. 

The anuria may be due to a spasmodic contraction of the vessels 
of the kidney. Here the drug that will overcome this nervous 
spasm is indicated. The most rapidly acting drug of this group 
would be the nitrites (hypodermically, as nitroglycerin ^V grain, 
0.001 gram), but probably the more efficient one because acting 
more on the nerves and less on the vessel walls would be atropin in 
the dosage of y^-g- of a grain (0.002 gram) hypodermically, repeated 
hourly until effective. If the anuria be only intermittent the bro- 



284 DISORDERS OF THE GENITO-URINARY SYSTEM 

mids might be sufficient if given in dilute solution in 15-grain 
doses repeated in four to six hours if necessary. 

On the other hand, if the anuria be due to a relaxed condition 
of the kidneys so that the blood pressure is weak, and the glomeruli 
so relaxed as to be inactive, vasoconstrictors are indicated. Of 
these, digitalis stands first, especially in the form of digitalin ( Ger- 
man, Merck) given hypodermically in doses of ^ to 2 grains. 
Diuretin, since it belongs to the xanthin group, will also be found 
of use in this condition, given in doses of 1 gram in dilute solution 
three times a day. 

Other drugs that might be tried to overcome this vascular re- 
laxation are the fluid extract of ergot, styptol, or stypticin, and 
adrenalin. All these are vasoconstrictors and would tend to raise 
the blood pressure and relieve the renal congestion. The fluid 
extract of ergot may be given in dosage of 1 fluid dram per os, or 
of the aseptic preparation 1 to 2 c.c. hypodermically. Styptol or 
stypticin would have a tonic effect in more chronic cases. The dose 
by the mouth is § grain up to twelve doses pro die. Adrenalin 
may be used intravenously in dosage of 10 to 25 drops of the 
1 : 1,000 solution for emergency service. 

If, on the other hand, the anuria be due to pathological changes 
in the kidney, it is best to relieve the kidney of all work, and stimu- 
late the skin and bowels to eliminate as much as possible of the 
waste products. Here drugs are of less use than baths, saline 
infusions, etc., the eliminant procedures mentioned under uremia. 

Oxaluria 

Oxaluria demands attention in that its continuance irritates the 
passages and may lead to the formation of calculi. Hence, the 
supply of oxalates in the food should be decreased (e. g., rhubarb, 
tomatoes, pineapples, apples, strawberries). The excessive use of 
sweets and carbohydrates should also be forbidden. 

The next step is to correct the digestive irregularities leading 
to the formation of oxalates. This is usually accomplished by cor- 
recting the condition of gastric subacidity (q.v.). In general, 
15 to 30 drops of dilute hydrochloric acid in plenty of water about 
thirty minutes after each meal furnishes sufficient acidity to over- 
come the lack of normal secretion. 



INFLAMMATIONS OF THE KIDNEY 285 

Phosphaturia 

Phosphaturia usually bespeaks nervous strain, and therefore 
calls for some regulation of the patient's activities. The amount 
of phosphates in the urine may be decreased by giving calcium car- 
bonate in 1 or 2 grain doses two or three times a day. 



INFLAMMATIONS OF THE KIDNEY 

Acute Inflammations 

Acute inflammations of the kidney are due to both toxic and 
rheumatic causes. In the majority of cases direct causal medication 
is not possible. Rather, our efforts must first be directed toward 
relieving the kidneys of their ordinary work, and secondly toward 
the elimination of the body's waste products through other channels. 

To bring about these results, the diet must be regulated so that 
foods making great demands upon the kidneys are not ingested, 
and the bodily activities must be reduced so that there is a smaller 
consumption of the nitrogenous tissues. And finally, vicarious 
elimination must be established through the skin and bowels. 

The kidneys seem to have the greatest difficulty in eliminating 
creatinin and phosphoric acid, hence all superfluous protein 
should be removed from the diet of the patient suffering from acute 
nephritis. In particular, we must avoid meat broths and soups. 
For this reason, milk has become the staple diet of patients suffer- 
ing from acute nephritis. Even this should not be given in exces- 
sive quantities, because we must save the kidneys from eliminating 
the extra fluid. Therefore, in acute nephritis from a pint to a 
quart of milk may be given daily for four or five days. In order 
to save the kidneys from the evil effect of the phosphorus in the 
milk, 15 grains of calcium carbonate should be given two or three 
times a day. To prevent the distress from the thirst, the patient 
should be given small pieces of ice as frequently as needed. Such 
starvation diet must be kept up for four or five days, an interval 
usually sufficient to overcome the acuteness of the inflammation. 

The patient must be kept in bed and protected from chilling 
influences. Not only so, but he should be given a daily sweat bath, 
either in the hot-water tub, the hot pack, or the hot-air cabinet. 



286 DISORDERS OF THE GENITO-URINARY SYSTEM 

The bowels must be kept active with saline cathartics or with 
enemata containing ox gall and magnesium sulphate. 

The pain is best relieved by the subcutaneous injection of atro- 
pin. If this is not efficient, morphin may be used. 

Hematuria. — Renal hemorrhage is relieved by ergot. This 
should be given subcutaneously. Therefore some nonirritating 
aseptic preparation, such as Parke, Davis & Co. 's, Mulford's, or 
Burroughs, Wellcome & Co.'s should be used. Otherwise, ergo- 
toxin intravenously or intramuscularly would be the choice (^hr 
to T V of a grain). 1 

If hematuria be the only symptom of renal disorder, it may 
indicate a need for calcium salts, that is, for a rise in coagulability 
of the blood. Of course if the disorder be due to calculus, surgical 
interference is called for (nephrotomy). 

In all cases of bleeding the use of hexamethylenamin (5 grains 
t. i. d.) is a wise prophylactic against renal sepsis. 

Hemoglobinuria. — Hemoglobinuria (as distinguished from hema- 
turia) may be due to toxic causes or to chilling of the body tissues, 
sometimes at considerable distance (e. g., the feet) from the kid- 
neys. Of the former the most frequent causes are potassium chlo- 
rate, guaiacol, coal-tar products, solanins, and some acids. Methem- 
oglobin also may be due to the ingestion of potassium chlorate 
and the coal-tar products. 

Hematoporphyrinuria. — Hematoporphyrinuria may be caused by 
sulphonal and trional. 

Naturally, the first step in the treatment of any one of the uri- 
nary disorders is to remove the cause by stopping the ingestion of 
the toxic drug or the continued chilling of the body. The second is 
to keep up the supply of oxygen to the tissues until new blood cor- 
puscles can be formed. The inhalation of oxygen may therefore 
be necessary. At any rate, tissue consumption must be reduced by 
means of bed rest and mental quiet, and the patient given fresh 
air under the best conditions for the hours and days during which 
the fresh blood is being formed. 

1 Since the above paragraph on Hematuria was written, evidence has 
appeared to show that adrenalin administered intramuscularly is better than 
ergot for hematuria: One c.c. of the 1:1,000 solution is injected deep into the 
glutei, and may be repeated in one or two hours. 



INFLAMMATIONS OF THE KIDNEY 287 

Chronic Inflammations 

Chronic Inflammations of the Kidney. — Before our treatment 
can be most effective, we must know whether the inflammation is 
of the parenchymatous or interstitial type. Our reason is that the 
regimen of the patient constitutes the most important part of the 
treatment, and this must vary with the type of the inflammation. 

The aim of all the treatment must be, of course, to protect and 
rest the renal tissues, to relieve and sustain the heart, and at the 
same time to nourish the patient satisfactorily. Thus foods that 
pass the kidney with difficulty must be avoided. In interstitial 
nephritis considerable fluid may be used to flush out, as it were, 
the kidneys. But in parenchymatous nephritis the quantity of 
fluid must be reduced. 

The amount of solids excreted daily must be watched as the 
index of the nutrition of the patient as well as of the efficiency of 
the kidneys. Of urea the urine of a healthy man should contain 
daily not less than 12 grams. This represents 85 to 90 grams of 
proteid food. A healthy man excretes from 13 to 17 grams of so- 
dium chlorid daily, although his actual need probably does not go 
much above 3 grams ; hence it is not the amount of fluid excreted, 
but rather the amount of solids that shows whether waste products 
are being retained in the system or not. Of course in studying 
these amounts, one must take into consideration the amount of 
food ingested before deciding whether or not the bodily equilibrium 
is being maintained. 

In parenchymatous nephritis, with scanty urine and edema, the 
reduction of the amount of fluid allowed the patient has a benef- 
icent effect on the edema as well as the quantity of urine, decreas- 
ing the former and increasing the latter. The minimum amount 
of fluid pro die is 1,500 c.e. (three pints). This takes into account 
the fluid in the food as well as that in the beverages. Not only is 
the fluid output increased, but the work of the heart is lightened 
under this reduction of fluids in appropriate cases. In this way 
the dry diet fulfills all the conditions laid down for the treatment 
of such cases. 

But where the heart is laboring and the kidneys seem unable to 
handle the excretion of the ordinary dietary products, the pure- 
milk diet is indicated. Two and a half to three pints of milk di- 
20 



288 DISORDERS OF THE GENITO-URINARY SYSTEM 

luted with sodium citrate, sodium bicarbonate, or Vichy water is 
the standard prescription for the adult. This diet gets rid of the 
excess of chlorids and similar irritants, but will not do for all cases 
or for any length of time, because it does not furnish sufficient 
heat energy to maintain the body in equilibrium. Thus, a man of 
125 to 150 pounds needs some 2,400 calories of heat energy. This 
would require the ingestion of some 3^ quarts of milk. Not only 
would this amount of milk be objectionable on account of the 
amount of the fluid, but also on account of the amount of protein 
thereby thrown into the body, 137 grams of albumen or 22 grams 
of nitrogen, that is, an amount double what is needed to maintain 
the protein balance. To obviate the difficulty, von Noorden x gives 
a milk diet made up of 1,500 c.c. of milk and 450 c.c. of cream. 
This amounts to 2,100 calories and 55 grams of protein. The heat 
energy is found in its 70 grams of sugar and 165 to 170 grams 
of fat. This diet does well for those convalescing from acute 
nephritis, and those suffering from parenchymatous nephritis. 

Milk is also poor in iron, hence a simple milk diet will not do 
for any length of time. Of iron a healthy man needs some .04 
grams daily; but even the 3J quarts of milk just mentioned con- 
tain only 0.12 grams, hence extra iron must be supplied to pa- 
tients living on a milk diet. On the other hand, milk is rich in 
phosphorus, and phosphoric acid is difficult for the kidneys to ex- 
crete. Hence, when giving an exclusive milk diet, one should add 
calcium carbonate or similar substance to precipitate the phosphoric 
acid in the intestine — e. g., 20 grains calcium carbonate t. i. d. 

Many suggestions have been made for diets giving all the ad- 
vantages, but none of the disadvantages, of the pure-milk diet. 
Thus Gouget prescribes 2 liters of milk, 250 grams of rice, 250 
grams of grapes, and 750 c.c. of Vichy water. Arrowroot and sago 
may be substituted for the rice. 

Now in any form of nephritis where there is great edema it 
has been found that a diet poor in chlorids brings about a reduction 

1 Forchheimer uses for similar reasons the following diet: 

Oatmeal jelly, made from 120 grams (4 oz.) of oatmeal 932 calories 

Milk, 1,000 c.c 893 " 

Sugar 205 " 

2,030 calories 



INFLAMMATIONS OF THE KIDNEY 



289 



of the edema. Hence, a milk diet is advantageous in dropsy for 
this reason also. The following are illustrative diets (Achard and 
Widal) that contain less than 2 grams of sodium chlorid: 1 



1. Milk . . . 
Potatoes 
Eggs . . . 
Meat . . . 
Barley . 
Sugar . . 
Butter . 



2. Bread (made without salt) 

Meat 

Legumes 

Butter 

Sugar 

3. Potatoes 

Meat 

Butter 

Sugar 

4. Potatoes 

Meat 

Butter 

Rice 

5. Bread (made without salt) 

Meat 

Butter 

Sugar 



1,000.0 

300.0 

2.0 

300.0 

200.0 

50.0 

40.0 

200.01 

200.0 

250.0 

50.0 

40.0 

1,000.01 
400.0 
80.0 
100.0 

1,000.0 

300.0 

50.0 

125.0 

500.0 
400.0 

80.0 
100.0 



I This affords 2,274 calories. 



This affords 2,200 calories. 



This gives 3,132 calories. 



(2.595 calories.) 



(3,037 calories.) 



1 To ascertain the salt cod tent of an ordinary diet the following figures will 
be useful. The following foods contain per kilogram: 

Milk 1 . 15 grams of salt 

Butter 1.0 

Eggs 1.5 

Rice 0.1 

Potatoes 0.5 " 

Oatmeal 0.4 

Peas 0.6 

Cooking vegetables in pure water reduces their salt content one part in the thousand. 



290 DISORDERS OF THE GENITO-URINARY SYSTEM 



6. Bread (made without salt) . 200.CT 

Potatoes 700.0 

Milk 50.0 

Butter 1,000.0 

7. Bread (made without salt) . 200.0 

Potatoes 300.0 

Rice 100.0 

Sugar 100.0 

Butter 25.0 



(2,450 calories.) 



(1,889 calories.) 



In nearly every case of nephritis we must forbid the use of 
more than 100 grams of protein pro die (=25.0 of urea). So 
also should we forbid all alcoholic drinks, spices, caffein, and 
nicotin. 

In the regulation of the patient's activities, we must also seek 
to spare the kidneys and circulatory apparatus, hence patients suf- 
fering from nephritis must avoid great exertion both of mind and 
body. They must take life easy; they must not confine themselves 
indoors, but must lead a varied existence, seeking as much as pos- 
sible of gentle out-of-door exercise. 

Of drugs we should make sparing use, reserving them for the 
time when stimulation or inhibition is required. We call upon 
them, therefore, to affect various symptoms. Thus to increase 
the quantity of urine in nephritis where there is no hematuria or 
sign of overstimulation, the sodium salicylate salt of theobromin 
has proven the most generally useful drug. This goes under the 
trade name of diuretin, and should be given in solution in doses 
of one half to one gram (five to fifteen grains) three times a day. 
Solutions of diuretin are best made with warm fluids; otherwise 
we are apt to have a cloudy preparation. 

When, on the other hand, there is a spasmodic contraction or 
great irritation in the kidney, we should use atropin in y-J-g-- to -jV 
grain doses (or ten drops of the tincture of belladonna). For 
similar purpose, in less acute cases, the bromids may be used in 
one-gram doses in solution. 

Most of the popular diuretics are valuable chiefly for the fluid 
they contain. 

In all cases of nephritis great assistance may be derived from 



INFLAMMATIONS OF THE KIDNEY 291 

the stimulation of excretion through the skin and bowels, as was 
suggested for acute inflammations. Hot-air baths and massage 
will do much toward lightening the work of the heart and kidneys. 
Hot-air baths may be given in bed by constructing an inclosed air 
space about the patient's body and running into that space air 
heated by the bedside. Thus wooden rods are extended from the 
foot to the head of the bed, some ten to eighteen inches above 
the patient's body and about three feet apart. Over these blankets 
are placed and tucked in so as to form a closed space extending 
from the patient's shoulder to his feet. Heat is generated in an 
alcohol or gas lamp and led into the cabinet through metal pipes. 
The patient should lie on a flannel blanket, under which is a rub- 
ber one. 

Sweat baths should, in general, be stopped when perspiration 
has stood on the patient's forehead for ten minutes. When pos- 
sible, the patient should then be briskly rubbed with lukewarm 
water and dried with a rough towel. 

Since a sweat bath lowers resistance to changes of air, an ambu- 
lant patient should rest in a warm room for at least an hour after 
the bath before exposing himself to any temperature changes. 

Suppurative Inflammations 

For suppurative inflammations of the kidney, in addition to 
the nonpharmacal procedures just outlined, hexamethylenamin 
should always be given. Its dose is five grains three or four times 
a day, either as a powder or in solution. 

Salol may also be used to render the urine antiseptic, but the 
antisepsis is decidedly weaker than that produced with hexameth- 
ylenamin (Sollman, Journal A. M. A., September 5, 1908). 

But in suppurative cases, wherever medicine does not afford 
speedy relief, surgery should be resorted to and the kidney irri- 
gated and drained. 

To ascertain whether one or both kidneys are affected, a cysto- 
scope should be used and the ureters catheterized. 

Only for a short time should we wait after making our diag- 
nosis before we call in the surgeon, because experience has shown 
that the prognosis in suppurative inflammations is exceedingly 
poor, and that the chances for recovery in the hands of a 



292 DISORDERS OF THE GENITO-URINARY SYSTEM 

skillful surgeon are better than when the disease is treated 
by drugs alone. 

Degenerative Inflammations 

Amyloid Kidney. — Amyloid kidney calls for a search for the 
cause. If suppuration or active syphilis can be demonstrated, it 
should be dealt with energetically, the former by operation, the lat- 
ter by potassium iodid in sufficiently large dosage. The kidney 
lesion must be treated just as any chronic inflammation is treated, 
by keeping the patient quiet and ordering the diet so as to relieve 
the kidney of unnecessary strain. 

Hydronephrosis. — Hydronephrosis is simply a result of the ob- 
struction of the ducts, hence the chief treatment is surgical — a ne- 
phrotomy to find the obstruction and, if possible, to remove it; 
a nephrectomy for a hopelessly atrophied kidney. The symptoms 
may be relieved by aspiration, but this is at best a measure for 
only temporary relief. 

Renal Calculus 

We might say almost the same for calculus as for suppurative 
inflammations, for unless our medication succeeds very promptly 
in quieting the disturbance the surgeon has a better chance of suc- 
cess with his mechanical treatment than we with our indirect 
methods. 

Whenever we diagnose the presence of calculi or of " gravel," 
uric-acid solvents are indicated. Probably the most effective of 
these are the piperazin group (lycetol, lysidin) and the hexameth- 
ylenaminae. We should not expect, however, to secure the solution 
of large concretions already formed; hence it is advisable to re- 
move by surgical means calculi already formed and then adopt 
such medical treatment as shall prevent their re-formation. For 
this purpose hexamethylenamin will prove most effective ; it should 
be given in doses of three to five grains t. i. d. Where an effort 
must be made to eliminate per vias naturales concretions already 
formed, atropin has proven quite helpful, because it anes- 
thetizes the mucosa and relaxes the tissues of the whole urinary 
tract. 



INFLAMMATIONS OF THE BLADDER 293 

INFLAMMATIONS OF THE BLADDER 

Cystitis 

Inflammations of the bladder are more often ascending than 
descending. In like manner they yield more readily to irrigation 
from the urethra than to drugs passing downward through the 
ureters. Ordinarily, however, sedative and antiseptic drugs are 
applied from both directions. We give drugs by way of the kid- 
neys in order to prevent the spreading of the infection upward 
as well as because it is generally easier to persuade patients to 
take drugs by the mouth than to permit thorough vesical irrigation. 

By the mouth we give the balsams, atropin, or bromids to quiet 
the irritation, and hexamethylenamin or salol to render the urine 
antiseptic. 

Of the balsams the sandalwood oil has the best reputation. It 
is given in capsules (to avoid irritating the stomach) in 5- to 15- 
drop doses several times a day. It is best given with milk or food. 

Atropin may be given in t Jq- -grain doses, or as the tincture of 
belladonna in 5- to 10-drop doses. 

Sodium or potassium bromid may be given in solution in water 
or in some pleasant vehicle in 15-grain doses. Three times a day 
is usually often enough for this drug. 

Hexamethylenamin is given in five-grain doses every four to 
eight hours. It may be given in solution, powder, or in tablet form. 

Salol is usually given as a tablet containing two to five grains. 
Thus in severe cases we would give five grains every four hours. 

For irrigation through the urethra we use potassium perman- 
ganate in 1 : 4,000 solution, or lysol in one-fourth- to one-half-per- 
cent solution, or a silver albuminate in five-per-cent solution. It 
is well to fill the bladder quite full of the solution and empty it 
twice or thrice and then fill it again, remove the catheter, and let 
the solution run out through the urethra. Such irrigation should 
be repeated daily, or even twice a day in severe acute cases. In 
chronic cases the interval may be longer. 

In acute cystitis we must also relieve the pain and discomfort. 
This is accomplished best with atropin and, where that fails, with 
morphin. 

Next we must render the urine less irritant. For this purpose 



294 DISORDERS OF THE GENITO-URINARY SYSTEM 



we increase the amount of fluid drunk by the patient. Hexa- 
methylenamin and methylene blue are given freely both for their 
soothing and their antiseptic effects. 

Then, as soon as the condition will permit, we introduce a care- 
fully sterilized and well-lubricated rubber catheter and irrigate the 
bladder with the appropriate solution. If the causative organism 
be the gonococcus, we use a silver albuminate (naturally less freely 
than we would the cheaper lysol). If the organism be simply one 
of the ordinary streptococci or staphylococci, lysol does well. Fur- 
ther along in the case potassium permanganate would be the anti- 
septic of choice because of its greater stimulation of the cells of 
the mucous membrane to regeneration. 

In chronic cystitis a careful study should be made to determine 
the cause — whether, for example, it is an obstruction in the ure- 
thra, as that due to an enlarged prostate, whether it is due to some 
inaccessible focus of suppuration, or whether it is due to a lack of 
reaction on the part of the body to some infection, such as gon- 
orrhea. 

In any case, the urine is rendered antiseptic and then the causal 
treatment is begun. Enlarged prostates are massaged or treated 
locally, or removed; abscesses are drained, and the patient's re- 
sistance raised by vaccination 
with weakened cultures of the 
infecting organism. 

At this point we may con- 
sider the technic of catheteriza- 
tion of which we have spoken 
in the preceding pages. 

Catheterization 

The female urethra is about 
two inches long, and therefore 
requires no particular technic 
in the way of catheterization. 
The chief emphasis in carrying out this operation needs to be laid 
on asepsis and gentleness. Probably beginners will have the great- 
est difficulty in dealing with female patients in finding the external 
orifice of the urethra, and one should hunt for it by starting from 




Fig. 44. — The Sinus Prostaticus. 



INFLAMMATIONS OF THE BLADDER 



295 



the clitoris and looking just below that for a minute depression or 
a collapsed opening. The glass catheter is the best for female pa- 
tients, for it can be thoroughly sterilized by boiling and shows when 
it is not clean. 

The male urethra, on the other hand, varies between 13 and 35 
centimeters in length. Sappey's investigation made the average 
length 16 centimeters. Naturally the 
length may be increased by stretching 
the membranous parts. The diameter 
of the dilated urethra varies ; 
it measures in the pars pros- 
tatica from 10 to lOf milli- 
meters; in the pars membra- 
nosa, 9 millimeters; in the 
pars bulbosa, lOf millimeters ; the ex- 
ternal orifice, 8 millimeters. It will 
be noticed that the external orifice is 
the narrowest and the part that is 
least capable of being dilated. There- 
fore, when instruments have passed this orifice they will meet in 
the normal urethra no further resistance from the size of the 
lumen. When they do meet resistance, it is probably because the 

instrument is being pushed into 
the pocket just in front of the 




Fig. 45. — Obstruction at the 
Mouth of the Urethra. 





Fig. 46. — Obstruction Offered by 
the Sphincter. 



Fig. 47. — Catheter Obstructed by 
the Sinus Pocularis. 



prostate, called the sinus pocularis. Just before the catheter passes 
into the bladder it will meet some resistance from the sphincter 
muscle which keeps the bladder closed. It should be remembered 



296 DISORDERS OF THE GENITO-URINARY SYSTEM 



that the pelvic floor is made up of a resistant membrane (triangu- 
lar ligament) through which the urethra passes. Therefore the 
beginner should try, by gentle means, to make the catheter fol- 
low the normal course instead of 
trying to force it through this 
ligamentum trigonum. 

The bladder normally con- 
tains from 250 to 500 c.c. of 
urine. Thus in a healthy twenty- 
seven-year-old man with a pres- 
sure of 14 to 16 centimeters, the 
quantity taken by the bladder 
was 250 c.c. A twenty-six-year- 
old man with 12 to 13 centi- 
meters pressure took 600 c.c. In 
a case of retention of urine in a 
thirty-six-year-old man, with a 
pressure of 14 to 16 centimeters, 
the bladder took 900 c.c. of fluid. 
In a case of hypertrophy of the prostate with a pressure of 9 
to 10 centimeters, the bladder content was 4,200 c.c. In a case 
of urine retention in a ten-year-old girl, with a pressure of 11 to 
12 centimeters, the urine in the bladder was 450 c.c. In a case of 
paraplegia in a twenty-nine-year-old woman, with a pressure of 28 
to 30 centimeters, the amount of bladder content was 1,200 c.c. In 
a case of retention of urine during a course of typhoid fever, with 
a pressure of 25 to 28 centimeters, the amount of fluid was 
2,100 c.c. 




Fig. 48. — Method of Pushing Cathe- 
ter Out op the Sinus Pocularis. 



IPs 



^ 



Fig. 49. — Metal Catheter for Normal Cases. 




Soft catheters are usually passed with less damage to the mem- 
brane of the urethra, at least by beginners, than are the metal 
catheters. For that reason they are to be preferred until one be- 



INFLAMMATIONS OF THE BLADDER 297 

comes thoroughly proficient. However, as soon as one meets 
obstructions in the course of the urethra, it will be necessary to 
use a metal instrument, and in using such an instrument one should 




Fig. 50. — Metal Catheter for Enlarged Prostates 



be careful to observe the natural curvatures in the body. In the 
first place, one should use a different curve for a normal individual 
than for a patient troubled with hypertrophied prostate. In the 
latter case there should be a much greater curve. 

To carry out the operation, the physician should stand on the 
left side of the patient, holding the penis parallel with the surface 
of the abdomen, introduce the catheter (lubricated with aseptic 




Fig. 51. — Position for Passing Catheter Under Pubic Arch. 

oil) gently, and force it down slowly over and around the pubic 
bone. As soon as it glides under the pubic bone, the instrument 
should be raised so that its point will look in the direction of the 



298 DISORDERS OF THE GENITO-URINARY SYSTEM 

axis of *the body. This point should hug the front wall of the 
urethra in passing through the prostate. This avoids the sinus 
pocularis. After safely passing this danger, there will be a feel- 
ing of obstruction from the sphincter muscle, and a gentle but 
persistent pressure will cause this to give way and the catheter 
to slip into the bladder. The mouth of the catheter should then be 




Fig. 52. — Position of Catheter After it has Entered the Bladder. 



depressed so that the urine may flow into the vessel held for it 
by the attendant. As soon as the flow checks up, the operator 
should press over the bladder area with his free hand to keep 
the flow going until the bladder be entirely empty. When the 
bladder is empty one should close the mouth of the catheter with 
his finger and withdraw the catheter quickly but gently, following 
the same course and using the same precautions that he used in 
inserting the instrument. 

It is unsafe ever to use a catheter without boiling it and taking 
it direct from the very water in which it was boiled, for the chief 
danger to be feared from the use of the catheter and from bladder 
irrigation lies in the introduction of sepsis; therefore not only 
should the catheter be thoroughly sterile, but also the whole area 
that is liable to be touched by the operator. In particular, the lu- 
bricant used for the mouth of the catheter should be thoroughly 
sterile. One of the easy things for a physician to do is to stick his 
dirty finger into a bottle of vaselin and rub it on the catheter, 
and then close up the bottle of vaselin ready to use again in the 



INFLAMMATIONS OF THE BLADDER 299 

next case. This, of course, is a sure method of ultimately produc- 
ing sepsis. By obtaining aseptic lubricant in collapsible tubes one 
may avoid this tendency. Vaselin may be sterilized by setting the 
bottle containing it (with the cork replaced by cotton) in boiling 
water for ten minutes after using each time. 

Before inserting the catheter the whole penis should be thor- 
oughly washed in hot water and soap and the glans penis in par- 
ticular cleansed with mercuric bichlorid (1:1,000). 

This same technic applies also for irrigating the bladder. First 
one should insert the catheter and empty the bladder. When the 
bladder is empty one should attach the tube of the irrigator to the 
mouth of the catheter and put the irrigating can just high enough 
to secure a regular flow. As soon as one half pint to a pint has 
been injected the solution should be allowed to flow out through 
the catheter. If this shows considerable detritus, the operation 
should be repeated in the same way. When the last filling of the 
bladder has been made, the catheter should be removed with the 
operator's finger checking any flow from its mouth and the patient 
instructed to hold the solution in the bladder for ten to fifteen 
minutes. This will lessen the danger of sepsis, because the anti- 
septic solution in flowing out will help to disinfect the entire 
urethra. 

Enuresis 

Enuresis is a symptom demanding a most thorough study as 
to its causation. Sometimes it is due to bad habits of life, some- 
times to peripheral irritation in and about the urethra, sometimes 
to psychic causes. 

Thus children should be taught to be regular and careful in defe- 
cation and urination, to empty the bladder before going to bed, not 
to eat inordinately just at bedtime, etc. The external genitals must 
be kept scrupulously clean. The clothing must not be irritating. 

Suggestive therapy will greatly help the patient to gain control 
of the sphincters after the physical causes are removed; that is, 
the encouragement of the patient to believe that he can and will 
control his urination. 

The use of cold baths and sprays assist in toning up the skin 
reflexes. Thus every morning a cold spray or rub should be given ; 
if necessary, more than one daily. 



300 DISORDERS OF THE GENITO-URINARY SYSTEM 

The food of the patient must be given regularly, and he must 
not be allowed to overload the stomach nor yet to become over- 
hungry. 

The bedclothing at night should not be so warm that the pa- 
tient sweats under it. The air of the sleeping room should be cold 
and pure. 

All cystitis (and enuresis almost always causes a subacute cys- 
titis) should be thoroughly treated by irrigations with antiseptic 
solutions and the administration of hexamethylenamin. 

Finally, for the irritability of the sphincters, atropin should be 
given in ^ to y-J^ grain t. i. d. 

Where the difficulty seems rather a lack of tone, the faradic 
current should be applied with one pole in the rectum or vagina 
and the other (sponge) over the bladder or over the spine. These 
treatments may be daily or on alternate days, and should be graded 
to the patient's resistance. 

INFLAMMATIONS OF THE URETHRA 

Inflammations of the urethra demand antiseptic irrigation. 
This is partially supplied by the urine when made antiseptic by 
hexamethylenamin; but, to be efficient, additional irrigation is 
needed. This is furnished by daily irrigations with the Valentine 
irrigator or similar apparatus and, when the bladder is also in- 
volved, by irrigations through a catheter into the bladder whence 
the solution flows through the urethra after the catheter is re- 
moved. Usually the bladder is filled twice and the solution allowed 
to escape through a catheter before the final filling is done and 
the catheter removed. 

Before the irrigation of the urethra, when that alone is in- 
volved, the patient should be caused to urinate in order to remove 
the detritus present. Then the solution should be injected into the 
urethra, either with a piston syringe or with an irrigator, just 
enough to fill the urethra, but not enough to distend it or force 
the virus into the posterior urethra. Naturally the injecting and 
emptying should be repeated several times at a treatment, and the 
treatment, in acute cases, repeated several times a day. In chronic 
cases the treatments are given at greater intervals. The Valen- 
tine apparatus enables one to use a larger quantity of the fluid and 



INFLAMMATIONS OF THE URETHRA 301 

regulate the force of the flow. To use it one should take a catheter 
or douche point small enough to let the solutions flow back outside 
it and insert it with the water flowing and gently push it for- 
ward for an inch or so, or just far enough to cover the affected 
area, and then run a pint or quart of the solution through the 
catheter. The operator needs to protect himself with rubber gloves 
and apron. The instruments should be sterilized both before and 
after using. 

The solutions used with the irrigators or douches are lysol 
(one fourth to one half per cent), hot nitrate of silver (1: 5,000), 
hot boric-acid solution (five per cent), permanganate of potash 
(1:4,000). For use with the piston syringe the albuminates of 
silver (e. g., argyrol, protargol) have been found best. These are 
used in strengths varying from five to ten per cent injected slowly 
and retained for several minutes. 

For the female urethra we cannot use irrigation effectively, 
but a similar effect is obtained by inserting bougies of cocoa butter 
mixed with the desired antiseptics. This dissolves in situ and thus 
medicates the membranes thoroughly. If now the urine be made 
antiseptic by the administration of hexamethylenamin it will wash 
out thoroughly the detritus and inhibit the bacteria. 

During the entire course of an acute urethritis, it is wise to 
keep the urine antiseptic and bland with hexamethylenamin and 
sandalwood oil. 

Chronic Inflammations 

Chronic inflammations of the urethra may be accompanied by 
stricture, and this furnishes an additional reason why the treat- 
ment needs to be local. The passing of sounds frequently enough 
to secure a permanent dilation of the stenosis, together with such 
antiseptic treatment as is necessary to clean out the infection, con- 
stitute the usual treatment. The solutions are practically the 
same as those for acute urethritis. 

Chronic Gonorrheal Urethritis 

In chronic gonorrheal urethritis (gleet, etc.) one follows the 
most logical line when he vaccinates the patient with weakened 
virus taken from cultures made from the urethral secretions. 



302 DISORDERS OF THE GENITO-URINARY SYSTEM 

I am indebted to Dr. R. B. Brewster for the following sugges- 
tions on the vaccine treatment of chronic gonorrhea: 

Chronic gonorrhea is often a mixed infection. In fact, many 
cases of the so-called chronic gonorrhea are not gonorrhea at all, 
but are chronic inflammations due to various other bacteria, the 
gonococci having long since died out leaving only the associated 
bacteria in their place. Since these other organisms are less toxic 
than the gonococcus, they give rise to less reaction, both systemic 
and local. This may be the reason why they are so apt to become 
chronic. Vaccine treatment is not indicated in any acute infec- 
tion, but when the body fails to develop a general immunity after 
developing a certain amount of local immunity, a vaccine may be 
brought into use to make all the body tissues assist in the immuniz- 
ing process. 

As long as there is systemic reaction " autovaccination " is 
taking place. When systemic reaction, as evidenced by pain, fever, 
swelling, is gone, but a discharge persists, it is wise to give vaccine 
therapy a trial. 

If microscopic examination of the urethral discharge shows the 
gonococcus to be the etiologic factor a stock vaccine may be used, 
of which we give a dose of 20,000,000 organisms subcutaneously 
every fifth day. Either dose or frequency or both may be gradu- 
ally increased if we keep within limits that will cause a very slight 
local reaction at the point of inoculation. 

The staphylococcus and pneumococcus are often found in the 
urethral discharge either separately or in conjunction, and still 
more frequently a short bacillus unknown to me. This bacillus has 
been found so frequently that I believe it to be a definite etiological 
factor. When these or other organisms are found it is practically 
useless to try stock vaccines, since the organisms are in varied com- 
binations and their strains are often very different from the stock 
vaccines in everything but morphology. For these cases an " au- 
togenous " vaccine should be used. The method is briefly as fol- 
lows: Have the patient present himself in the morning before he 
has urinated. Wash out urethral meatus with sterile water and 
open the meatal lips, reach into urethral canal with sterile plat- 
inum loop. Make smears on slide for identification purposes. 
Plant secretion on agar slants. Make six plants on as many tubes, 
distribute evenly over surface and incubate twelve hours. Exam- 






INFLAMMATIONS OF THE URETHRA 303 

ine microscopically and compare with slide so as to know what 
organisms you have to deal with, then wash off growth in 5 or 10 
c.c. sterile normal salt solution. Hermetically seal this bacterial 
emulsion in a test tube, shake to break up clumps, and subject to 
60° (Centigrade) water bath for one hour. Now pour into a bottle 
containing 30 c.c. sterile physiological salt solution to which has 
been added one fourth of one per cent lysol or carbolic acid. 

All methods of standardizing vaccine by making bacterial 
counts of the emulsion are laborious, and the results are so unre- 
liable that many have discontinued making such counts, but de- 
pend upon a microscopic estimation of the gross growth upon agar 
to determine what the dilution shall be — i. e., whether the sterilized 
emulsion shall be put into 25, 30, 40, or 50 c.c. of diluent nor- 
mal salt solution. The only standardization worth while is the 
amount of reaction in the patient. Commence with a small dose 
and increase it gradually until you get a mild local reaction of 
soreness and brawny induration over an area less than one inch 
from point of puncture. 

So successful have the vaccines been that a failure is always 
laid to a failure to secure the proper organism ; hence another vac- 
cine is made in an attempt to get the true etiologic organism. 
Naturally saprophytes are more easily cultivated than parasites, 
hence the latter are sometimes hard to secure. It is almost im- 
possible to get cultures of gonococcus to grow, hence a stock vac- 
cine should be used, when this is the offending organism, by every- 
one unprovided with a complete laboratory. Cultures that have 
been kept growing for years on artificial media can be secured, and 
they are comparatively easy to handle, but it is well-nigh impossible 
to carry freshly secured culture of gonococcus to a second genera- 
tion in a test tube. 

Unfortunately for the vaccine therapist the cervical discharge 
in the female is strongly antiseptic, and although bacteria are 
found plentifully in smears, cultures can rarely be obtained. 
Hence the alleviation of cervical, uterine, and tubal infections can 
only be brought about when we have stock vaccines that are more 
efficient than they are at present. 



21 



304 DISORDERS OF THE GENITO-URINARY SYSTEM 



GENITOURINARY INFLAMMATIONS IN THE MALE 

Inflammations of the Prostate 

Inflammations of the prostate also demand local treatment — 
if pus be present it must be drained out, otherwise the irritation 
may be allayed by the application of belladonna (atropin) and 
soothing oils to the walls of the urethra at the points nearest the 
gland. External applications of heat and cold are also helpful. 
Internally we give sandalwood oil and hexamethylenamin. 

In detail, the tenesmus and dysuria are relieved by giving inter- 
nally sandalwood oil (5 drops) and tincture of belladonna (6 to 10 
drops). Since the former is irritating to the stomach, it is best 
given in capsules and after meals. The latter may be given in 
water or other vehicle. Bitterness is its only drawback. The in- 




Fig. 53. — Treatment of the Prostate Through the Urethra (Overall). 



fection is combated by making the urine antiseptic with hexa- 
methylenamin (3 to 5 grains t. i. d.). Acute cases cannot be treated 
by passing instruments through the urethra. Hence we must 



GENITO-URINARY INFLAMMATIONS IN MALES 305 



have recourse to hot baths (sitzbader) . Hot cloths (fomentations) 
also afford some relief. Guaiacol and similar analgesics may be 
applied externally over the perineum to relieve some of the distress. 
The patient must lie in bed and use only a light diet of nonirri- 
tating food. 

In chronic cases the local treatment with electricity is worth 
trying. For this the galvanic current is used and treatments 
begun with strengths of 5 to. 10 milliamperes for one to three 
minutes. This may be combined with cataphoresis wherein a drug 
in ointment form is applied to the prostatic area of the urethra 
before the electrode is inserted, and then the negative pole inserted 
at the proper place and the current turned on. To diagnose and 
treat this condition, as well as the others of the urethra, one should 
master the use of the cystoscope. Otherwise he cannot locate and 
evaluate local erosions and inflamed areas. For the ointment the 
ung. belladonnas of the 
Pharmacopeia will do 
as well as more expen- 
sive preparations. 

One may use the rec- 
tum for securing access 
to the prostate when the 
urethra is too inflamed 
for such service, and 
massage of the pros- 
tate through the rec- 
tum has proven very 
efficient ( Forchheimer ) . 
For this treatment the 
patient assumes the 
knee-elbow position and 
the physician inserts the 
forefinger of his right 
hand (protected by a 
rubber glove) and 
kneads the enlarged 
glands. At first the treatment must be very short and gentle. 
After a few treatments they may be prolonged to two to five 
minutes. 




Fig. 54. — Treatment of the Prostate Through 
the Rectum (Overall). 



306 DISORDERS OF THE GENITO-URINARY SYSTEM 

If after a week's energetic treatment the enlarged gland is not 
reduced, the surgeon should be called upon to do a prostatectomy. 

The drawing off of residual urine with a catheter should be 
taught the patient only as a last resort. When it is so taught, great 
emphasis must be laid on asepsis, both in the way of cleaning the 
catheter, in using only sterile lubricants, and in washing the penis. 
It is better to have a prostatectomy done and permanent relief 
thereby obtained. 



Inflammations of the Epididymis and Testes 

Inflammations of the vas deferens and epididymis are usually 
secondary to urethritis and prostatitis. Only in the case of tuber- 
culosis, mumps, and influenza does it appear primarily in the 
deeper structure. 

The condition demands first of all rest. The patient should re- 
main in bed and the whole scrotum should be raised and supported 
by bandages so that there is no strain on the ligaments, and the 
return flow of blood is free and unhindered. 

If there is great pain, heat should be applied by means of the 
thermophore, antiphilogistin, or moist hot cloths. If no pain, cold 
should be applied to check the extension of the inflammation. 

There is little or no direct drug therapy. One may, however, 
secure some sedative effect by applying menthol and guaiacol oint- 
ments locally. Internally one may give hexamethylenamin and 
laxatives (e.g., calomel). 

The addition of an orchitis to the epididymitis hardly changes 
the therapy. Here the swelling makes the bandaging more im- 
portant. 

Tuberculosis demands surgical interference and the removal of 
the diseased tissue. 

Functional Disorders 

The functional disorders, spermatorrhea and impotence, de- 
mand a study of their causation. If, as is usually the case, they 
are functional, systemic treatment (especially suggestive therapy) 
is called for. The habits of the patient must be corrected — all ex- 
cesses in work, play, venere, and baccho must be checked. Obesity 



GENITO-URINARY INFLAMMATIONS IN FEMALES 307 

must be treated. Constipation and indigestion must be relieved. 
On the other hand, out-of-door exercise and wholesome pabulum 
for the body and mind must be provided. 

Should there be a tendency to local congestion, local cold baths 
and rubs should be prescribed. Should there be a sort of ischemia, 
means for producing a local hyperemia should be exhibited. 

Of drugs, strychnin for its general tonic effect, ergot for its 
stimulant effect on the smooth muscles, and yohimbin to congest the 
pelvic viscera, may be exhibited. Or, if the patient be nervous, 
the consistent use of the bromids may bring about a functional 
cure. 

In general, however, it is the hygiene of body and mind that 
is most needed by these patients, hence the chief duty of the 
physician is to examine each patient thoroughly from head to foot 
and ascertain, if possible, his whole curriculum vitas before out- 
lining his therapy. Then, after all, it may be simply friendly 
counsel and encouragement that is most needed. 



GENITO-URINARY INFLAMMATIONS IN THE FEMALE 

Endometritis 

Inflammations of the uterus are due to infection by way of the 
vagina and require local treatment. The patient must be quiet, 
the bowels kept free, and the diet light. Pain is usually not severe 
if the patient remain quiet; hence the greater part of the treat- 
ment is directed toward keeping the drainage free and checking 
a spread of the inflammation. For the former, antiseptic douches 
are used at least once a day, with practically the same solutions 
that we named for cystitis. The vagina may have to be swabbed 
out daily with hot sponges under the guidance of the eye (specu- 
lum). If there seem to be a gathering of pus, this of course must 
be drained. Otherwise no active operative interference is at- 
tempted until the process has become circumscribed or chronic. 

To prevent the spread of the inflammation, we depend upon 
rest and cold. The former keeps the blood current from pick- 
ing up extra infection, and the latter inhibits the activity of 
the inflammation. Cold is best applied by an ice bag over the 
hypogastrium. 



308 DISORDERS OF THE GENITO-URINARY SYSTEM 

The use of hexamethylenamin or salol to render the body fluids 
less hospitable to bacteria is generally approved. 

When the acute stage is over, the question of the value of dila- 
tion and curettement should be brought up. Its purpose is to 
remove the foci of infection from the endometrium, and to free the 
uterus from adhesions and scar tissue. 

The reflexes of the patient may demand some sedation. For 
this, valerian and the bromids seem most successful. The former 
may be given as the ammoniated tincture in 1 or 2 c.c. (-J dram) 
doses. It is well to use plenty of fluid in the vehicle, and glycerin 
with the simple elixir may be added to make the dose a teaspoonful 
and then the whole is given in hot milk or water. The bromids 
may be given in doses of 1 gram (15 grains) in water or hot milk. 
Either drug may be repeated in four hours if needed. 

Salpingitis 

There is little hope of medicinal treatment for inflammations 
of the tubes. If they be distended with pus, some method of drain- 
age should be sought, for the tubes can hardly be expected to be- 
come patent again after such a suppurative inflammation. On the 
other hand, chronic inflammations with thickening may be treated 
by the application of ichthyol to the vaginal vault (ten per cent 
ichthyol-glycerin suppositories). This drug stimulates the local 
tissue building to the extent of softening scar tissue and relieving 
the tension of adhesions. The use of heat over the hypogastrium 
to induce local hyperemia is also of benefit. 

In addition to the local measures (especially in the chronic 
forms of the disease) the ordering of a quiet life, the providing of 
free saline cathartics, the use of massage and hot baths will all 
tend to shorten the time of recovery. 

The relief of the pain must first be brought about by analgesics. 
But in a day or so, the causal therapy (either the evacuation of 
the pus or the hyperemia) will also relieve the pain and the other 
most troublesome symptoms. 

Oophoritis 

The ovaries are so inaccessible that therapeutic measures must 
be more or less systemic to affect them. Thus the application of 



GENITO-URINARY INFLAMMATIONS IN FEMALES 309 

heat or cold is less effective than in the corresponding lesion of the 
male, but such measures do have an effect and should not be for- 
gotten. 

The source of the inflammation is generally from the tubes, and 
therefore liable to be complicated with a more or less circumscribed 
peritonitis. On the other hand, there are inflammations of hema- 
togenous origin which give rise to symptoms more or less neuralgic 
in character. 

In view of the inaccessibility of the organ, the decision as to the 
presence of pus must rest on the leukocyte count rather than on the 
result of digital examination. When pus is present the desirable 
procedure is to drain it with as little destruction of the functions 
of the ovaries and tubes as possible. Hence, a conservative surgeon 
should be called into the case. 

When pus is not present, the treatment is medical. The patient 
must go to bed. Heat must be applied to the lower abdomen until 
an active hyperemia is produced. If great tenderness exists, guaia- 
col and methyl salicylate may be applied in conjunction with the 
heat. As usual, they may be used in strengths of twenty to fifty 
per cent in oil or ointment. The bowels must be kept active, both 
by cathartics (calomel or salines) and hot enemata. The diet 
should be light. If great pain persists, the coal-tar derivatives 
seem more effective than morphin. 

Bartholinitis 

Inflammations of the glands of Bartholin need the same general 
treatment that similar inflammations elsewhere would require. 
Thus pus must be evacuated and the interior cleansed with 
hydrogen peroxid or some other antiseptic. The chief need is to 
keep the gland open and draining, rather than any particular 
drug application. 

Similarly the cervical glands should be opened and drained 
whenever distended or inflamed. These are sometimes obliterated 
with phenol or nitrate of silver after cleansing. 



CHAPTER VII 
DISOKDEKS OF THE NEKVOUS SYSTEM 

INTRACRANIAL DISORDERS 

Intracranial disorders demand in general the reduction of 
bodily activity to the minimum. Therefore, the patients are put 
to bed in quiet, darkened rooms, and cold applied to the head and 
back by means of ice bags or Leiter 's coils. 

Next, the intestinal tract is cleansed from all debris by thor- 
ough initial purging with calomel and the salines or castor oil. 
The emptying of the bladder also must be carefully supervised 
and catheterizing done when there is a well-grounded suspicion 
of retention. 

The diet is restricted to those substances that make the least 
demand on the digestive apparatus, such as peptonized milk, cus- 
tards, junkets, eggs, etc. The food should be given in small quan- 
tities and at frequent intervals. 

The skin is carefully looked after with frequent rubs with oil 
or alcohol, as the condition may warrant. 

Severe pain is usually relieved by acetphenetidin or the other 
coal tars. 

Intracranial congestion, when not sufficiently relieved by the 
cold, may be treated by the application of a leech (or a cup) be- 
hind each ear (particularly efficacious with children). 

Aggressive therapy is possible only when we can open the skull 
and mechanically repair the lesion, when we can give a specific 
drug (as the iodids in tertiary syphilis), or when we can inject 
an antitoxic serum. Hence the diagnosis of the cause of the dis- 
order is of the utmost importance, and no test should be omitted — 
e. g., the Wassermann reaction for syphilis, the lumbar puncture 
(Quincke) for microbic infections, or the study of the retina for 
neoplasm and pressure symptoms. 
310 



INTRACRANIAL DISORDERS 311 

Prophylactically much can be done to avoid cerebral complica- 
tions. Thus in diseases where there is danger of thrombosis and 
embolism, every effort should be made to prevent the dislodging of 
the clot. In particular, such patients should not be allowed to 
move until all danger of embolism is past. In another class of 
cases, such as purulent inflammations of the sinuses and middle 
ear, free opening and drainage of the pus should be undertaken 
before it has had time to penetrate to the meninges. In septi- 
cemias the head should be kept cold and the patient very quiet 
to prevent the localization of secondary foci in the intracranial 
vessels. The use of hexamethylenamin in septicemia would find 
justification if it did nothing more than render the cerebrospinal 
fluid resistant to infection. 

Encephalitis can be treated only by the general measures just 
named (rest, cold applications, etc.), except where an abscess can 
be made out. Whenever this is done the abscess should be opened 
and drained. 

Hemorrhage requires measures to lower the blood pressure 
within the skull and measures to promote the absorption of the 
exudate. The first is obtained usually by dilating the blood vessels 
of the lower extremities, and by doing venesection (whenever not 
contraindicated by the underlying disease). The latter is sought 
by promoting the general metabolism. Of drugs for this purpose, 
potassium iodid is the most popular, and this is frequently given 
in immense doses (see Syphilis). The food must be nutritious. 
The emunctories must be kept active. For reawakening the dam- 
aged nerve centers, strychnin is the best drug (e. g.,iV grain every 
four hours) . For the principles of treatment when arteriosclerosis 
is the cause of the hemorrhage, see that section. 

Tabetic Processes. — The tabetic processes (e. g., in paresis) in 
the brain substance are regarded as hopeless. The giving of potas- 
sium iodid in large doses sometimes seems to have an influence for 
good. 

Embolism. — Embolism may sometimes be helped by increasing 
the flow of blood to the head (to overcome the ischemia and its 
consequent softening of brain substance). To accomplish this the 
patient is laid on a bed with head low and feet high. Strychnin 
and potassium iodid are used to stimulate the circulation and tissue 
building. 



312 DISORDERS OF THE NERVOUS SYSTEM 

Neoplasms. — Neoplasms require surgical treatment. When that 
is unavailable the quiet life of an arteriosclerotic (q. v.) should be 
enjoined. 

Sunstroke. — Sunstroke leaves results that can be removed only 
by hydrotherapeutic and hygienic treatment carried on for a long 
time. That is, by means of massage and baths we endeavor to reju- 
venate the brain tissues along with the other tissues of the body. 
The principle of procedure is the familiar one of combining hot and 
cold baths, exercise and rest, and regulating the food to develop 
to the maximum the process of tissue repair. 

Hydrocephalus. — For hydrocephalus little can be done. The 
puncture of the ventricles and of the lumbar cord will relieve the 
temporary danger of death, but it seldom saves the child from be- 
coming imbecile or idiotic. 

Infantile Cerebral Palsy. — Infantile cerebral palsy may be 
treated by the iodids and strychnin, but the results are very dis- 
appointing. It has been suggested that prophylactically one could 
do much by giving pregnant syphilitics a thorough course of the 
iodids. 

Meningitis. — Ordinarily meningitis is divided into two varieties, 
the tuberculous and the nontuberculous type. The former is re- 
garded as being always fatal, and the latter is so in more than 
three fourths of the cases; hence the therapy of the condition is 
largely palliative. The patient should of course be put into bed 
and the head packed in ice in order to decrease the amount of irri- 
tation of the cerebral centers. The chilling of the tissues seems 
to have a good effect in inhibiting the rapid multiplication of the 
microorganisms, as well as in giving some comfort to the patient. 
In the way of internal antiseptics, hexamethylenamin, salol and 
guaiacol are generally used, the two former given in the dose of 
5 grains every two hours for the adult. For children, smaller doses 
in proportion should be given. The guaiacol should be given ex- 
ternally (15 grains in the fifty-per-cent oil solution rubbed in on 
the abdomen three times a day). 

For the stimulation of the vital processes as long as possible 
strychnin is used. This may be given hypodermically in ^ of a 
grain every four hours for an adult. 

The intestinal canal must be kept free. For this purpose calo- 
mel is probably the best drug. The preliminary cleansing may re- 



INTRACRANIAL DISORDERS 313 

quire a saline purge, but after that a grain of calomel daily in 
divided doses will prove sufficient, unless the patient be too coma- 
tose to take drugs per os. In this case enemata with ox gall would 
help keep the intestines clear. 

A prescription embodying the above is as follows : 

1J Hexamethylenaminse 3.00 gms. 

Tct. nucis vomicae 0.70 c.c. 

Ext. colocynthidis compositi 0.05 gms. 

Glycerini 50.00 c.c. 

Elixiris gentianse glycerinati 50.00 c.c. 

M. D. S. : One teaspoonful every three hours. 

Or, if a capsule or powder be preferred, the following might be 
used: 

1^ Phenylis salicylatis 6.00 gms. 

Strychninae sulph 0.04 ' ' 

Hydrargyri chloridi mitis 0.20 " 

M. f. capsular (vel. chart.) no. XX. 

The lumbar puncture referred to above is of sufficient impor- 
tance to devote some space to its discussion. Upon it we must often 
depend for our diagnosis of the lesion, but its use has also been 
of immense importance in relieving the intracranial pressure in 
hydrocephalus and tumors, and it has also enabled us to replace 
inflammatory spinal fluid by fresh sterile saline solution. 

Lumbar Puncture. — Quincke introduced, in 1891, lumbar punc- 
ture as a method not only of diagnosis but also of treating cerebro- 
spinal meningitis. In that year he reported 22 cases in which he 
had made 42 punctures. Piirbringer reported 45 cases in 1895 
in which he had made 100 punctures, and in 1896 Lenhartz re- 
ported 150 punctures and later 230 in 126 patients. The method 
is, of course, of particular use with children, but the technic should 
be at the disposal of the general practitioner because it is applicable 
to the treatment of tetanus, as well as for the spinal analgesia with 
novocain and stovain. 

Anatomy. — The lower end of the spinal cord (conus terminalis) 
reaches in adults the level of the arch of the first or second lumbar 
vertebra. In children it reaches a little lower, usually to the third 



314 



DISORDERS OF THE NERVOUS SYSTEM 



lumbar vertebra. From this point downward the dnral sac (cis- 
terna cerebrospinalis) is filled with the cerebrospinal fluid in 
which the scattered bundles of nerves which compose the cauda 
equina float freely, so that when a needle is inserted into this space 
the nerves are not injured thereby. 

The subarachnoid space communicates with the brain ventricles 
by means of the foramen Magendie, and also two additional open- 
ings in the roof of the fourth ventricle. The foramen Magendie 

may measure as much as 
6x8 mm., but the two 
other openings are very 
much smaller. Because 
of these openings there 
should be free communi- 
cation between the lumbar 
space and the lateral ven- 
tricles of the brain. In- 
creased pressure in the one 
place should show itself in 
the other almost immedi- 
ately. When this does 
not occur it is due either 
to the obstruction of the 
passages or to a change 
in the character of the 
fluid. The ligamentum 
denticulatum keeps the 
membranes lining this 
space under normal con- 
ditions apart. 

The space- between the 
arches of the third and 
fourth lumbar vertebrae is 
the largest, although that 
of the fifth, while some- 
what flatter, is usually 
somewhat broader. These openings usually measure 18 to 20 
mm. in width and 10 to 15 mm. in height. However, they be- 
come smaller with age, therefore it is much harder to find the 




5th space 



Fig. 55. — The Spaces for Lumbar 
Punctures. 



INTRACRANIAL DISORDERS 315 

opening in adults than it is in children. For this reason it is 
necessary with adults to insert the needle at a greater angle than 
with children. 

Technic. — It is usually preferable to have the patient lie on one 
side, although it is easier to have the patient sitting with the body 
bent forward on the hips as far as possible. A line is drawn be- 
tween the two cristas ilii. This line usually passes over the spinous 
process of the fourth lumbar vertebra. Therefore we should locate 
with the finger the next spinous process above, and when dealing 
with, children, insert the needle under this third process. With 
adults and with some children it is necessary to begin the insertion 
•J to 1 cm. to the side of the median line and then direct the needle 
upward and medianward until it reaches the free space under the 
spinous process. Usually the needle penetrates the muscles and 
fascia easily, and if one has directed it right one feels at the dis- 
tance of 5 or 6 cm. in adults (less in children) that the resistance 
to the movements of the needle has lessened, and if one now re- 
moves the mandrin, fluid usually begins to escape. Before insert- 
ing the needle the skin must be thoroughly disinfected as for any 
operation, with soap and water, alcohol with sublimate, or iodin. 
AVith patients suffering from tetanus it is usually necessary to 
chloroform them before the body is relaxed enough to slip the 
needle under the spinous process. 

The first drops of fluid may be bloody. These should be caught 
in a sterilized test tube, and as soon as the fluid begins to run clear 
a second test tube should be substituted for securing the rest. It 
is best to have these test tubes graduated in order that one may 
know exactly how much fluid he has taken out. Under ordinary 
conditions 20 to 30 c.c. will flow out spontaneously. Under in- 
creased pressure as high as 75 to 100 c.c. may flow. But the 
removal of this latter amount may be accompanied by the danger 
of terrific headaches and spinal pains. If the fluid does not flow 
freely, one should have the patient sit up for a moment until it 
does start, or else one should reinsert the mandrin of the needle 
to see that the lumen of the needle has not been clogged with coagu- 
lated fluid or by a nerve fiber. 

Instruments. — One may use the ordinary aspirating needles, 
but one should remember the danger of breaking such needles if 
one by accident hits the bone; therefore when possible the instru- 



316 DISORDERS OF THE NERVOUS SYSTEM 

ments devised by Quincke himself should be used. The outfit 
usually consists of two (Quincke) needles about 1\ cm. long and 
from T 6 o- to 1^ mm. in diameter. These needles should be fitted with 
small steel mandrins pointed at the anterior ends the same way that 
the needle is pointed. Second, there should be several wide gradu- 
ated test tubes sterilized ready to receive the fluid. Third, it is wise 
to have instruments for measuring the pressure, and this in the 
Quincke outfit consists of a thin rubber tube to one end of which 
is attached a metal connection fitting the canula or needle, and 
to the other end of which a narrow glass tube on which is marked 
the millimeters to indicate the height of the fluid therein. 

The flow of the fluid should occur by drops. If it starts to flow 
out under pressure one should check it every moment or two in 
order to prevent too sudden a change of pressure within the spinal 
canal. On the oher hand, one should not aspirate in case the fluid 
does not flow, but should make sure that the needle is within the 
proper space and is free from clots. In some cases it is necessary 
to withdraw the needle and reinsert it. 

At the close of the work one withdraws the needle quickly and 
seals the opening with cotton and collodion. 

The greatest difficulty comes from the striking of the bones. 
This may break off the needle or bend it. When one hits a bone 
one should not withdraw the needle completely, but should with- 
draw slightly and move the point about in search for the open 
passage ; then, of course, if an open passage be not found, the 
needle may be entirely withdrawn and a new insertion made. 
There is some danger lest one push the needle across the spinal 
canal and through the anterior wall of the lumbar sac into the 
body of the vertebra in front. In this case the fluid flows only 
after one has withdrawn the needle somewhat. 

The normal fluid contains \ per mille (Jacobi 0.2 to 0.5 per 
mille) of albumin, and in the case of meningitis the albumin may 
rise to 1 t 8 q- per mille (" one per mille means inflammation, ' ' 
Jacobi) and brain tumors to 2y 2 o per cent. As soon as this in- 
crease in albumin occurs, coagulation is more rapid and fluid 
may coagulate even while running out. The specific weight is 
about 1.002 to 1.009, and reaches in pathological cases as high as 
1.011. Sugar is found in very small quantities normally, but is 
much increased in tumors. The finding of microorganisms in the 



SPINAL DISORDERS ■ 317 

fluid is, of course, of great diagnostic value. The normal fluid 
is clear. 

In using lumbar puncture for the introduction of drugs into 
the spinal canal one should be careful either to withdraw as much 
fluid as one introduces or should use the spinal fluid itself to dis- 
solve the drug (e.g., novocain). To avoid this necessity we often 
make our solutions so concentrated that we need to introduce only 
a few drops, as in the case of magnesium sulphate when injected 
for tetanus. 

To secure relief from too great pressure we should let just 
enough flow out to make the pressure normal (5 to 35 mm. of mer- 
cury or 40 cm. of water). This usually requires not more than 
30 c.c. 

SPINAL DISORDERS 

Chronic Pachymeningitis. — Chronic pachymeningitis should be 
treated surgically. Laminectomy should be done over the affected 
area and the meninges irrigated with corrosive-sublimate solution. 
(Horsley.) 

Myelitis. — If myelitis be due to the pressure of an abscess, the 
latter should be opened and drained, otherwise the patient should 
be kept very quiet, with just enough gentle massage and electrical 
treatment to keep the skin and muscles of the affected area from 
atrophying. It is wise to strap the patient to a board or frame in 
order to facilitate treatment. The worst that can be done is to use 
the so-called osteopathic movements; for by keeping the spine at 
rest there is a chance that the process will heal, but by moving the 
spine we simply damage the tissue and cause the disease to spread. 
The use of hexamethylenamin and strychnin in these disorders is 
justified. If the underlying process be tuberculosis, the appro- 
priate regimen should be adopted (see Phthisis). 

Anterior Poliomyelitis. — Anterior poliomyelitis should be treated 
by electricity, the iodids, and strychnin, to promote tissue repair, 
cell regeneration, and renewal of function. The electrical current 
should be just strong enough to stimulate gently, not strong enough 
to injure. Thus 30 milliamperes of the constant current for five 
minutes a day is regarded as the maximum. Of course the bowels 
and bladder require constant watching, especially if the innerva- 



318 DISORDERS OF THE NERVOUS SYSTEM 

tion be damaged. Sometimes in this disease the supply of nutri- 
tion to the affected areas of the spinal cord may be reestablished 
during the fever by stimulating the general bodily processes, at 
the same time keeping the patient as quiet as possible, with ice 
applied along the backbone. Sometimes also the symptoms of this 
disease are caused by intestinal intoxication, and in such cases 
complete relief may be obtained by active catharsis, followed by 
careful dieting and antisepsis of the intestinal tract. 

For the recovery of the motion in the parts of the body sup- 
plied by the affected nerves, it is important that those muscles be 
kept quiet in the days immediately following the attack ; and thus, 
instead of giving active massage and movements, the muscles should 
be incased in cotton batting and restrained from all activity. 
Later on, electricity and massage may be used with good effect. 

The use of iodids here, as in other nervous diseases, to bring 
about the absorption of the exudates and the reestablishment of 
the normal tissue has become routine treatment. For children, 5 
grains of the potassium iodid three times a day will be sufficient. 

Finally, the stimulation of the regenerative powers is influenced 
by strychnin, and therefore this drug should also be used. For 
instance, we might combine the medicines as follows: 

^ Tinct. nucis vomica? 10 

Potassii iodidi 7 

Elixiris gentiana? glycerinati (N. F.) 60 

Sig. One teaspoonful three times a day. 

For stimulant electricity the sinusoidal current seems to have 
proven most effective. The one electrode should be applied to the 
feet and along the affected muscles, while the other electrode should 
be placed at the back of the neck. If the former be a roller, mas- 
sage can be utilized with the electricity. 

Tabes Dorsalis. — It is not to be hoped in this condition to restore 
function to the affected nerve trunks. Therefore, the best that can 
be done is to establish function through the development of new 
nerve paths. This consists in teaching the patient to use the af- 
fected muscles carefully and slowly, one action at a time, just as 
one would teach a baby to walk. 

The nerve tissues involved may sometimes be helped by the 



SPINAL DISORDERS 319 

exhibition of the iodids and by the regular application of high- 
frequency currents. Both of these measures simply mean a quick- 
ening of the metabolic processes in the area of the affected nerves. 

The pains have to be treated symptomatically with the coal-tar 
derivatives or opiates. The use of electricity and massage some- 
times is sufficient to keep such pains under control. 

Optic nerve atrophy and similar dystrophies seem benefited by 
strychnin. 

In general, tabetics do best in sanatoria, where they may have 
the advantage of freedom, and on the other hand have carefully 
directed exercise, diet, and treatment. If everything goes well, 
the disease may after months of treatment be arrested and the 
patient live in comparative comfort for years. 

The principle upon which such treatment is laid down is that 
of developing new conduction paths between the brain and the 
periphery. This is accomplished by passive movements : i. e., mak- 
ing a set of muscles perform a set of movements over and over 
until they do it almost automatically. This is practically the 
method by which we all learn to use our muscles in our infancy 
and childhood. Hence painstaking oversight and appropriate ma- 
chinery are necessary for the successful treatment of tabetics. 

Tetanus. — Tetanus may be treated by the injection of magne- 
sium sulphate in twenty-five per cent solution, 4 c.c. at a dose. 
Injection should be between the third and fourth or between the 
fourth and fifth lumbar vertebras. For instance, insert the needle 
2 cm. to the side of the median line on a level with a line extend- 
ing between the highest points of the iliac crests. No solution is in- 
jected until a few drops of clear (not blood stained) cerebrospinal 
fluid have escaped. The injections lessen the rigidity and the 
suffering, and should be repeated as soon as the rigidity becomes 
extreme. The magnesium sulphate employed should be the pure 
salt, such as Squibb 's, and the solution should, of course, be steril- 
ized by boiling. 

The following case histories illustrate the value and applica- 
bility of this therapy (from Medical Fortnightly for April 10, 
1909; Dr. A. P. Heinecke, of Chicago) : 

Case I. — Robinson, G. Cany. Treatment of tetanus by intraspinal 
injection of magnesium sulphate. (Jour. A. M. A., 1907, Vol. XLIX, p. 



320 DISORDERS OF THE NERVOUS SYSTEM 

493.) Male, eleven years ; weight, 67£ pounds. Contusion of scalp. Pre- 
vious immunization, none. Played considerably around stable. Ex- 
cised supposed wound of entrance. Chloral hydrate, gr. 30, sodium bro- 
mid, gr. 60, every twenty-four hours for the first two weeks. On the 
eleventh day of the disease patient was anesthetized. Ethyl chlorid 
used as a general anesthetic. Three c.c. of a twenty-five-per-cent solu- 
tion of magnesium sulphate injected in subarachnoid space. On the next 
day repeated injection using 3^ c.c. On the fifteenth day of disease 
injected in same locality 4 c.c. of same solution. Recovered. Author 
states that the intraspinal injections of magnesium sulphate produced 
marked lessening of the very severe symptoms for a number of hours. 
The muscular rigidity was never so severe after each injection as it had 
been before. 

Case II. — Miller, Robert T. Treatment of tetanus with subarach- 
noid injections of magnesium sulphate. (The Am. Jour, of the Med. 
Sciences, 1908, Vol. CXXXVI, p. 781.) Male, seven years; weight, 60 
pounds. Period of incubation, seven days. Previous immunization, 
none. Lacerated wound of left hand. Antitoxin daily for fourteen 
doses varying from 1,500 to 7,000 units. Sedatives for a short time. 
Copious saline enemas and infusion. Eleven lumbar punctures made 
within thirteen days. Approximately 25 c.c. of a twenty-five-per-cent 
solution of magnesium sulphate being injected into the meninges at each 
puncture. Recovered. "Of the value of the treatment of magnesium 
sulphate, no one who witnessed this case has any doubt. The muscular 
paralysis following each injection lasted from eighteen to twenty-nine 
hours. It involved all muscles, except those of head, neck, and dia- 
phragm. The injections were followed several times by respiratory col- 
lapse, lasting from eleven to fourteen hours, and the pulse dropped 
though not to a dangerous degree. 

Case III. — Henry, John Norman. (International Clinics, 1908, series 
18, Vol. IV, p. 1.) Male, nine years. Period of incubation six weeks. 
Previous immunization, none. Abrasion of skin of back by kick of 
horse. Lumbar puncture 3 c.c. of twenty-five-per-cent solution of mag- 
nesium sulphate injected in subarachnoid space. Five days later sub- 
arachnoid injection repeated. Recovered. The case was a severe one. 
Made excellent recovery. Each injection was followed by a relaxation 
of the rigidity. 

NEUROSES 

The neuroses require more general bodily treatment than do 
most of the localized or organic nervous diseases. This is due to the 



NEUROSES 321 

fact that a neurosis is essentially a symptom, or symptom-complex, 
the cause of which is only dimly understood. Hence we must try to 
influence all the bodily processes that could in any way have an 
influence on the symptoms. We have to use shotgun rather than 
rifle methods. 

"We need, therefore, to increase the patient's weight if he be 
emaciated, or decrease it if he be obese. We need to regulate the 
diet, the mastication, the environment, and the habits of the pa- 
tient. We must prescribe the exercise and rest, the baths and the 
rubs, the sleeping hours and the working hours — all this in order 
to furnish to a deranged nervous system a better body or body 
machinery upon which to work. 

Because arsenic stimulates the nutrition of the nervous system 
we use arsenic in most neuroses. In other cases the catabolic 
power of the iodids seems more to be desired. Again we need 
the stimulant power of strychnin or the depressant action of a 
bromid. 

Anemias must be corrected by the administration of iron. Irri- 
tation from faulty vision must be helped by well-fitting glasses. 
Reflex irritation from a hooded clitoris, an adherent prepuce, or an 
anal fistula must be searched out and relieved. In short, we must 
not rest until we have corrected all the abnormalities of the body 
and done everything to soothe and help the mind. 

Mania 

This condition is usually due to an exaltation of the cerebral 
centers. Therefore those drugs are indicated which have specific 
action in depressing the cerebral centers. Of these, scopolamin 
(hyoscin) stands foremost. It should be used hypodermically in 
y-J-jj- of a grain to -^ of a grain every four hours if needed. Hyos- 
cyamin and atropin are less specific in action and should be used 
only when there is an accompanying excitement of the peripheral 
nervous system. It should be remembered that -j-J-g- grain of 
hyoscin is combined with J grain of morphin for an anesthetic. 
The result of the giving of such a combination is profound sleep, 
which may sometimes be very desirable to secure in mania. In 
such sleep the patient's respiration may be reduced to four in 
the minute, and may become stertorous in character. The skin of 



322 DISORDERS OF THE NERVOUS SYSTEM 

the face is cyanotic, due to the dilation of the skin capillaries. As 
long as the pulse is regular and not below 50, and the respira- 




Fig. 56. — The Permanent Bath for Quieting Mania. 
(Clow's System.) 




Fig. 57. — The Permanent Bath in Use in a Hospital for the Insane. 
(Clow's System.) 



NEUROSES 323 

tions keep up from 4 to 8 in the minute, little danger is 
ordinarily to be apprehended from this depression of the res- 
piration. 

Whenever possible, the so-called permanent bath is preferred 
for quieting mania. The patient is put in a tub and a heavy canvas 
cover fitted about his neck and arms in such a way that he cannot 
leave the tub or injure himself. Patients are left in such baths 
if necessary for twenty-four hours or more. The water is, of 
course, kept at a constant temperature by regulating the in-and- 
out flow, so that the patient soon falls asleep under its admin- 
istration. 

Soothing rubs and the application of heat will also be found 
helpful for quieting maniacs. 

The administration of food and the stimulation of the emunc- 
tories should not be neglected with these patients. The use of 
gavage by a tube through the nose may have to be resorted to. In 
such cases, warm broths, peptonized eggs and milk are used. The 
cathartic salts meet the needs for relieving the system of waste 
products better than the other cathartics, because they would 
carry off the detritus which in health would pass through the 
kidneys or the skin. 



Chorea 

This is a functional disorder, and usually due either to an over- 
use of some part of the nervous system or an intoxication of some 
region of the central nervous system. Thus girls at school, where 
they have become excited about their work and pursued it too 
vigorously, are quite often subject to attacks of chorea, or children 
who do not care for the regular evacuation of the bowels and blad- 
der, and, on the other hand, eat inordinately and at all times of 
candy and delicacies, are also liable to the disorder. (This type 
of chorea should, of course, be carefully differentiated from that 
type which depends upon congenital weakness.) In general, 
therefore, chorea is best treated by putting the patient absolutely 
at rest in bed, and in giving at first depressants, and afterwards 
tonics, until the equilibrium of the body is reestablished. For pre- 
liminary depression, acetanilid has been recommended, although 
since it is a coal-tar product one should be very careful in its use 



324 DISORDERS OF THE NERVOUS SYSTEM 

and not permit it to affect the circulation. Hyoscin or hyoscya- 
min would be found useful, which, depending upon whether the 
choreic exaltation seems to psychic or lower down. Hyoscyamin 
for medullary or lower exaltation should be given in the dose of 
y-J-g- of a grain three times a day. The hyoscin for exaltation of 
more psychic character could be given in tJ-q of a grain. The 
nutrition of these patients is usually improved by the use of 
arsenic and iodids. The arsenic is for the purpose of stimulating 
the nutrition of the nervous centers, while the iodid hastens the 
processes of metabolism. For such purposes, Donovan's solution, 
which contains the arsenic iodid as well as the mercuric iodid, 
would probably be most indicated. This should be used in ordi- 
nary patients in the dose of 5 drops three times a day. The drug 
is more effective if given before meals. 

Where anemia is present, iron should be used, and in general 
the character of the drug depends upon the findings in the blood 
examination. 

As soon as the patient has overcome the worst twitching, he 
should be put into out-of-door life — made either to lie on a couch 
(well wrapped, of course) in the sunshine, or if more vigorous, 
given plenty of active exercise. 

Epilepsy 

The pathology of this condition has not yet been fully worked 
out. It is probably some interference with the cerebral centers. 
When the interference is in the cortex, we have the Jacksonian 
type of epilepsy, which is usually successfully treated by surgical 
interference. When the lesion is deeper in the brain the only line of 
treatment possible at present seems to be the depression of the nerve 
centers and reflex arcs. The drug that has proven most effective 
for this purpose is the bromid, which probably in most cases would 
better be given in the form of the sodium salt rather than that of 
the potassium, because the sodium salt is less destructive to tissue 
in its action. 

Patients suffering from this disease should be kept out of doors 
in as pleasant surroundings as possible and every effort made to 
increase their bodily strength. Thus the farm colonies which are 
now used by the more progressive of the state governments for 



NEUROSES 325 

the care of their epileptics form a great advance over the old-fash- 
oned asylums, with their lack of light and air. 

In treating epilepsy great stress must be laid on keeping the 
digestive tract active and clear. The chief liability is to constipa- 
tion and intestinal autointoxication ; hence, in giving the bromids, it 
is well to combine them with stomachics and cathartics, according 
to the need of the individual patient. The following prescription 
will serve to illustrate the point: 

^ Sodii bromidi 20.0 gms. 

Ext. fl. cascaraa sag 7.0 c.c. 

Tinct. gentian, co 30.0 " 

Glycerini 60.0 " 

Aquae 90.0 " 

Sig. One dessertspoonful t. i. d. 

There are constantly being added to our materia medica new 
compounds and forms of nerve depressants, such as sabromin, bro- 
mural, which may be used when for some reason the ordinary 
bromids are inapplicable. 

Hysteria 

So far as we know, hysteria is purely a functional disease. It 
seems to be due to a labile condition of the central nervous sys- 
tem, so that slight stimuli (even so slight that the normal organism 
would react without damage) cause in the hysteric a complete 
alteration of the mode and characteristics of their lives. For this 
reason, as far as drugs are concerned, the treatment is one of de- 
pression of the reflex arcs. It is not yet clear why it is, but valerian 
and the aromatic sedatives seem to be more useful for this than 
the simpler bromids. Thus the tincture of valerian (which is a 
twenty-per-cent solution) given in teaspoonful doses has proven 
quite effective even when other drugs that seemed to have a reason- 
able basis for their administration have failed. Even more ef- 
fective than the plain tincture is the ammoniated tincture, also a 
twenty-per-cent preparation, given in a 2-c.c. dose, well diluted. 
Bromural and veronal, which seek to combine the actions of the 
bromids and valerian, would also be useful. 



326 DISORDERS OF THE NERVOUS SYSTEM 

But it is in hysteria that psychotherapy finds its true field. 
Psychotherapy includes suggestion, persuasion, reeducation, hyp- 
notism, and the other intangible therapeutic measures advocated 
at different times and under various names. 

In its essence psychotherapy seems to be the transference of the 
patient's attention from his bad feelings and weaknesses to points 
on which his feelings seem good and he appears otherwise strong. 
It centers his attention on his hopes rather than his fears. It 
teaches him to be thankful for what he has rather than to mourn 
for what he has not. How this change of thought affects the body 
processes can, of course, only be theorized about; but, in general, 
we may say that it does enable all the metabolic processes to act 
more easily and uniformly, and that this in turn makes the mind 
feel better. 

The difficult part in psychotherapy lies in the securing of the 
patient's attention and belief. It is to this part that the manifold 
procedures and methods are really directed. In general, we may 
say that it is essential that the patient listen to the physician, and 
that he will do this only when he consciously or unconsciously as- 
sumes a receptive attitude toward the physician. For this reason 
some psychotherapeutists secure the attention of their patients by 
unusual actions and motions, by exhibiting bright objects upon 
which the patients must fix their attention, or even by putting 
the patients to sleep (hypnotism). We may even say that unless 
the patient can and will fix his attention successful treatment is 
impossible, hence the insane and imbecile are not amenable to psy- 
chotherapy. 

Wherever possible, acute cases should be treated by isolation 
and quiet, bland diet (e.g., milk), and cheerful suggestions from 
the nurse and doctor. The patients must be made to feel that 
they have the sympathy of both nurse and doctor, that everything 
is being done for their benefit, and that they will get well if they 
will only resign themselves to the doctor's direction and attention. 
Such patients improve in nutrition, weight, and feeling under this 
regime. 

The isolation is possibly the most important part of this treat- 
ment, because it gives them rest and also frees them from harmful 
suggestions from ignorant and thoughtless comrades. It meets a 
need which we all feel now and then — a need of seclusion, of re- 



NEUROSES 327 

treat from the world, of freedom from responsibility and care. 1 
This isolation is, of course, best brought about in a hospital in a 
private room with a special nurse, but it may be done fairly well 
at home if one can secure the proper nurse. For, after all, it is the 
nurse who makes or breaks our treatment of this class of cases. 
She must be a woman who has lived and thought as well as have 
received the technical training of a nurse. It is better not to at- 
tempt the isolation, treatment at all than to try to use an incom- 
petent nurse. 

The milk diet is usually kept up for a week, or until the diges- 
tion and defecation are normal and the patient is relieved of the 
many somatic disturbances accompanying the disease. We usually 
give four to eight ounces of full milk, or milk mixed with car- 
bonated water, every three hours. 

The daily visit from the doctor is quite important. At this 
visit the doctor should encourage the patient, point out his im- 
provement, and tell him that his nervous troubles are curable and 
will gradually disappear. With some patients we use reeducation ; 
that is, we try to explain and persuade, showing them their real 
condition and teaching them how to overcome the pathological 
tendencies. With others we must work through the emotions rather 
than the reasoning faculties; that is, we employ suggestion. We 
tell them that they are going to get well and use every opportunity 
to force home that suggestion. 

Hypnotism is therefore needed in the few cases where we can- 
not use reeducation or waking suggestion. We hypnotize by fix- 
ing the patient's attention and then suggesting sleep, meanwhile 
providing all the conditions helpful to somnolence, such as quiet, 
comfort, warmth, etc. As soon as the patient is completely passive 
we give our therapeutic suggestions, repeating them until they 
become fixed in the patient's mind. We must repeat the seance 
before the patient can quite return to his old condition of thought 
and feeling, be it in a few hours or a day or two ; hence hypnotism 
is used more in those cases where the patient visits the doctor's 
office and where the latter is not able to control the environment of 

1 Its value is beautifully shown in Robert Herrick's admirable tale, " The 
Master of the Inn," published by Scribners, which every student of medicine 
should read. 



328 DISORDERS OF THE NERVOUS SYSTEM 

the patient. Its danger is that it tends to make the patient more 
dependent upon the doctor, rather than more independent. There- 
fore, if we believe that the doctor's mission includes the moral one 
of making his patients stronger and better, we must conclude that 
hypnotism is distinctly inferior to reeducation. 1 

Hypnotism. — Dr. Munro thus outlines his usual speech to a 
patient when he uses a small vial of water : 

Take this chair, please. Now, I will explain to you what I am doing 
and what I wanted with you. Do you see this little bottle of medicine ? 
This is a sample of a preparation that I am introducing to the physi- 
cians, known as " Somno- Analgesic Compound." " Somno " means sleep 
producing and " analgesic " means pain relieving ; so then this is sleep- 
producing and pain-relieving medicine. It is used by rubbing it on the 
forehead just as you see me rub it on mine. You notice it does not 
harm me and it will not harm you. Now I have explained to the phy- 
sicians here that in order for this remedy to have its effect it must be 
applied in a certain way, and that is the way that we get our patient 
to do and to be while the medicine is applied that determines its effect. 
I want you to take a seat in this chair, lean your head back against 
the wall, relax ' every muscle, close your eyes slightly, and breathe 
through your mouth, just as if you were going to sleep. Then, as I 
apply the remedy, you will soon get quiet all over, then get drowsy and 
sleepy, and go to sleep, and awake feeling better. Now see here, my 
man, don't resist the effect of the medicine ; just sit here, and let it have 
its effect. 

The same author gives the following outline for his method 
when he uses no object: 

All right, take this seat. Lean your back against the wall. Close 
your eyes lightly and breathe through your mouth and think of going 
to sleep. Now, as I apply this remedy, you will soon become quiet all 
over and get drowsy and sleepy, and go to sleep, and awake feeling 
better. 

I will talk to you to help you concentrate your mind. Now, as I 
apply this remedy, you will get sleepy, sleepy, sleepy, sleepy, so-o-o-o 
sleepy. Now go to sleep, sleep, sleep, sleep. 

Now you feel quiet all over. Your muscles are relaxed. Everything 



1 As an illustration of the actual methods used by hypnotists, I quote the 
following examples from a text-book on the subject by Munro. 



NEUROSES 329 

is dark to you. You do not hear anything but my voice. You are 
drowsy and sleepy, so-o-o-o-o sleepy. You feel the sleep coming over 
you. You are going to sleep, sleep, sleep, sleep. 

By the time I count ten you will be fast asleep. One, two, three, 
four, five, six, seven, eight, nine, ten, and you are asleep, fast asleep, 
sound asleep. 

By the time I count five more you will be sound and dead asleep, 
just as you are in the dead of night when sleeping soundly in your 
own bed. One, two, three, four, five, and you are asleep, fast asleep, 
sound asleep, dead asleep. Don't wake now until I tell you. 

Every second your sleep will become sounder and sounder and deeper 
and deeper. Sleep on quietly until I wake you. 

Now you will not hear anything or feel anything or know anything 
except what I tell you. Sleep on quietly until I awaken you. 

After the patient is asleep usually something is done to com- 
plete the effect — to convince him, so to speak, of the operator's 
power. Dr. Munro 's method is as follows : 

Sleep on quietly. When I count three this arm will be stiff (raising 
his arm), so stiff that you cannot take it down. One, two, three; your 
arm is stiff and you cannot take it down until I tell you. Now when I 
rub this medicine on your arm three times it will be dead and have no 
feeling in it. Now I pinch this arm (thrusting a pin through a fold 
of the skin), but you do not feel it; there is no feeling here at all; this 
arm is perfectly dead. 

The therapeutic suggestion is then given; given in simple lan- 
guage, slowly and distinctly. If necessary, the suggestion is re- 
peated several times before waking the patient. 

For waking the patient some suggestion as the following is 
given : 

Now, my man, when I count three you will open your eyes and be 
wide awake. You will be feeling good all over. You will remember 
nothing that has been said or done, and will find that you never felt 
better in your life, and will always be glad that you came up here. 
One, two, three, and you are awake. 

The following case history from Barker (Am. Jour. Med. Sci., 
October, 1906) illustrates the use of reeducation in the treatment 
of neuroses : 



330 DISORDERS OF THE NERVOUS SYSTEM 

Reeducation. — Case History: insomnia, incapacity for work; fear 
of insanity; obesity; rapid cure; weight reduced twelve pounds. 

Mr. P., aged fifty-six years, married, was admitted November 18, 
1905, complaining of nervousness, inability to sleep, and fear of going 
insane. 

His mother had died insane, and one of his brothers had also been 
insane. 

In childhood the patient suffered from measles, scarlet fever, and 
whooping cough. At twelve years he passed through an attack of 
typhoid, and at fifteen had malarial fever. He denies venereal infec- 
tion. His habits have been good as regards alcohol and tobacco. 

The patient states that he has always been a nervous man, and that 
for the past nine or ten years, dating from a period of worry over ill- 
ness in his family and certain business troubles, he has been much 
more nervous and sleepless; has found himself incapable of attending 
properly to his business affairs. For the past two or three years he has 
been seriously incapacitated, often being compelled to stay away from 
his business, that of a storekeeper, for days at a time. He ascribes 
this incapacity to general lack of interest and energy. Lately he has 
been growing irritable, worrying easily over small matters, though he 
knows that it is nonsensical to do so. He thinks that his memory is 
somewhat impaired, and states that he suffers from insomnia nearly 
every night. He always feels worse in the morning, whereas before 
going to bed at night he sometimes feels in perfect health. The appe- 
tite has been variable. The bowels move regularly. 

On examination the patient is found to weigh 185 pounds, though he 
is not a tall man. Patient does not look ill, and mentally he seems 
clear. The pupils react to light and accommodation. There is no 
glandular enlargement. The lungs are normal. On examination of the 
heart the point of maximum impulse is not easily visible or palpable. 
The deep cardiac dullness extends 8.5 cm. to the left of the middle line 
in the fifth intercostal space. The heart sounds are normal, and the 
pulse is regular in force and rhythm. The radial artery is not palpable. 

The abdomen is pendulous, owing to the large amount of fat in the 
abdominal wall. The examination of the abdomen is otherwise nega- 
tive. The knee kicks are present, but not overactive. Cremasteric and 
plantar reflexes normal. No objective disturbance of sensation. Sta- 
tion good; Romberg's sign negative. Examination of blood: red blood 
corpuscles, 4,830,000; white blood corpuscles, 5,800; hemoglobin, eighty 
per cent; no parasites. 

A careful ophthalmoscopic examination was made by Dr. Bordley 
and the disks were found normal. The patient had some esophoria. 



NEUROSES 331 

The patient was told that he was too fat, and that his weight should 
be reduced. He was also informed that a majority of his symptoms 
were of nervous origin, and that they were curable. He was encouraged 
to think that there was no reason why he should go insane. During the 
first few days he was kept in bed, upon a low milk diet, after which he 
9 was placed upon a reducing diet. Erom day to day he was encouraged 
as to his progress and told that we believed he would get well. After a 
time he was given regular room gymnastics, nearly all of the muscles 
being exercised in this way. Later still, he was made to walk, the dis- 
tance being increased each day until he walked five miles every day. 
He was then advised to take a few Turkish baths before going home. 

The reducing diet contained 140 grams of proteid, 30 grams of fat, 
and 112 grams of carbohydrates, so that he received some 1,320 calories 
a day. He lost twelve pounds in weight in the seven weeks, regained 
energy and courage, and was discharged November 18th feeling per- 
fectly well. Some months later his brother entered the hospital for 
treatment, and reported that the patient had been perfectly well ever 
since, and was doing his work with entire satisfaction to himself and 
his family. 

It would not be surprising if he should relapse later, as the case 
seems to fall in the group of the " periodical depressions." 

The results of the psychotherapeutic treatment of hysteria by 
Charcot in Paris and Barker in Baltimore (treatment continued 
for several months) show about fifty per cent of cures. That is, 
the suggestive therapeutic method requires a long continuance of 
treatment to insure permanency in the results. 

Hydrotherapy. — Hydrotherapy has also been called into use for 
hysteria. The following case from Baruch's text-book shows the 
difficulties as well as the success that may attend the work. 

A. F., aged fifteen years, was brought to the Hydriatic Institute 
July 19, 1892, by his father, who said that on March 21, 1892, on the 
day of his daughter's burial, the boy " fainted." Ten days later he 
fainted in school, and again two days later. The family physician in- 
vestigated the case at school, concluding that it was a form of epilepsy. 
The boy was kept from school and put on potassium bromid. The at- 
tacks becoming more frequent a prominent neurologist was called in 
consultation ; the same treatment was continued. He continued to have 
attacks every day, and very often twice a day, lasting from five to ten 
minutes. At first he lay unconscious without any movement whatever; 
then the attacks became violent, frequently requiring several men to 



332 DISORDERS OF THE NERVOUS SYSTEM 

hold him down and prevent him from doing himself bodily harm. 
The former consultant was again called in and made an unfavorable 
prognosis. Several neighboring physicians who had been called during 
the attacks gave him hypodermics of morphin. Patient also received 
electrical treatment from his own physician. 

Status Prcesens. — Face pale, covered with acne, eyes restless, hand • 
tremulous, appetite fair but capricious, gastric oppression after meals, 
bowels constipated. Patient appeared to be brominized. 

Treatment. — Resorcin, three grains in a half pint of hot water, an 
hour before lunch and dinner. He was ordered to be at once well 
scrubbed with soap and water. This was followed by a wet pack (sheet 
wrung out of water) at 70° F., reduced two degrees; this to be followed by 
a rain douche at 90° F., twenty-five pounds pressure, gradually reduced 
during thirty seconds to 75° F. 

August 20th : This treatment had been used daily, the temperature of 
the douche being reduced two degrees every day. He had a slight 
attack five days after treatment was begun ; none since. He was ordered 
to Long Branch to take surf baths. 

September 29th: Patient has called on me several times, reporting 
steady improvement. He was discharged cured. The patient has re- 
mained well. 

False Angina. — Mr. D., merchant, aged forty years, weight 190 
pounds, of robust appearance, has suffered for several months from 
agonizing pains in the precordial region whenever he attempted to walk 
briskly, especially after meals. He was completely disabled from busi- 
ness. His family physician regarded the case as one of angina pectoris, 
and this diagnosis was confirmed by an eminent consultant. He was 
advised to use amyl nitrite pearls for the attacks and give up business. 
In consequence of this decision he became melancholic, and when he 
applied for treatment he was a picture of woe. He gave a gouty his- 
tory ; urine normal but loaded with urates ; digestion impaired ; pulse of 
high tension. He was restricted to a nonmeat diet, put upon glonoin 
and strychnin. A wet pack, water at 60° F., was ordered daily for one 
hour, followed by rapid ablutions with water at 50° F. ; a wet compress 
to be worn all day, wrung out of water at 60° F. No preparatory treat- 
ment to ascertain his reactive capacity was needed, because he was 
a robust man of splendid physique. The aim of treatment was the 
enhancement of tissue change, a calming effect with stimulating sequel. 
This was happily accomplished because the patient was careful and 
frightened. He did not neglect treatment. In three months the fre- 
quency and intensity of the attacks had so far diminished that I per- 
mitted him to take a journey of some weeks. On his return dyspeptic 



NEUROSES 333 

symptoms were more pronounced. He was put upon chopped beef, pre- 
ceded by a pint of hot water, for breakfast and dinner; oysters and hot 
milk for luncheon. Four months later he was entirely free from pain 
and had lost some flesh, but was able to bear the worries of business. 
Although five years have elapsed he remains in good health. 

These case histories illustrate perhaps better than a descrip- 
tion the necessary features of the successful treatment of hysteria. 
Nothing that does not make a profound impression on the patient 
will succeed, hence the treatment must be vigorous, aggressive, and 
compelling, no matter whether psychotherapy, hydrotherapy, or 
pharmacal means be employed to restore the patient to health.' 

Neurasthenia 

This disease will form the bulk of many a young doctor's ini- 
tial practice, and his success in handling these sufferers will greatly 
influence his general success in practice in that locality. 

The first indication is for rest and the second for graduated 
exercise. The first restores normal function to the body, the sec- 
ond redevelops the power and self-confidence of the patient. These 
sufferers are usually afflicted with a congenital disposition to en- 
teroptosis. This makes necessary medication to correct dyspepsia 
and constipation, and also stimulation of the digestive processes. 

The following case histories from Baruch are instructive, both 
as to the condition of the patients and the methods of successful 
treatment : 

Case I. — Neurasthenia Psychopathica. — Mrs. , aged forty 

years, from San Francisco, has four children; perfectly well for eighteen 
years. Since birth of last child, seven years ago, has been ill. At that 
time, her husband being very sick, great demands were made upon her. 
"Went to the World's Fair in 1893 in charge of a party, but found her- 
self suddenly incapable of continuing and was compelled to return home. 
During the next three years she spent most of the time away from home 
on account of " distressing nervousness." She now went to Japan on 
account of her husband's health. She " could not account for her great 
depression during the sojourn in this interesting country, and constantly 
trembled at the thought of resuming her role in life, because she had 
misgivings as to her ability." On her return in October, 1895, to use 
her own language : " I was careless, forgetful, indifferent to everything, 



334 DISORDERS OF THE NERVOUS SYSTEM 

and excitable, restless, and fickle-minded to a distressing degree. My 
ordinary duties became a burden, a decision on any point, however 
trivial, was an impossibility." She took a partial rest cure at home, but 
found it necessary to go to a private sanatorium. She was nervous, dis- 
tressed, dissatisfied without cause, felt she was of no use to anyone, a 
detriment to those nearest and dearest to her, and she was therefore will- 
ing to live apart from them. She " remained away a whole year without 
feeling maternal ambition, lost interest in everything. She had mas- 
sage, steam and shower baths triweekly; she lived and dragged 
herself wretchedly, feeling that she had sacrificed her position in the 
home." 

On her return home she suffered unspeakably; was now, as she had 
always been since her illness, subject to insomnia. She again felt im- 
pelled to leave home and went to relatives. Her uterus was now curet- 
ted. She felt better until she got up ; then " doubts, fears, questions as 
to the best course to pursue," returned ; she " felt that she had lost 
her grip." Her hearing being much impaired added to her mental dis- 
tress. She now came to New York. 

October 5, 1897 : Mrs. — presented herself in order to try systematic 
hydrotherapy as a last resort. She stated that her " life during the past 
year has been spent in idleness, dreading the coming of sunshine in the 
morning and of the darkness at night; the thought of her husband and 
children deserted was maddening; sorrow had taken the place of peace, 
irresolution was her bane." She presented no organic disease; weight, 
stripped, 107 pounds ; nutrition much below par, appetite poor, sleep im- 
perfect. Ordered careful regulation of diet, exercise, rest, and a grad- 
ually developed hydriatic treatment, patient being placed in charge of 
a nurse. 

October 7th: A preparatory douche, 95° to 85° F., produced an hys- 
terical attack. 

October 20th: Becoming gradually accustomed to the treatment, she 
took to-day a circular douche, 95° to 90° F., of one minute, followed by 
Charcot (fan) douche, 78° F. for ten seconds. Her weight has increased 
three pounds. 

Mental condition unsatisfactory. Nurse is suspicious of suicidal 
intent. 

October 22d : Lost one pound in weight and is much distressed by the 
fact. Ordered hip bath 85° F. for five minutes, followed by fan douche 
to back, 78° F. for ten seconds, to be reduced daily one degree. 

November 13th : Took the same hip bath followed by fan douche, 74° 
F. for ten seconds. He gained four pounds, but expresses no satisfaction 
over gain. Is extremely despondent, sighing, and irresolute. 



NEUROSES 335 

November 28th: Hip bath, 85° F. for eight minutes, followed by jet 
douche to back, 65° F. for fifteen seconds, and fan douche, 70° F. for ten 
seconds. Has lost two pounds; greatly dejected by the loss. 

December 5th : Treatment continued with daily reduction of douche 
temperature and increase of duration. To-day she took a jet douche 
to back, 58° F. for twenty-two seconds, and general fan douche, 65° F. 
for ten seconds. Weight increased three pounds without remark by 
patient. 

December 12th: Weight increased two pounds, total increase being 
eight pounds. Mental condition better. Patient " sees some ray of 
hope." 

The hip bath was now ordered alternated with perspiration bath to 
stimulate tissue change. The urine had become scant, with an increase 
of urates and phosphates. 

January 1, 1898 : Under this treatment she did not improve. She 
was saddened over a loss of three pounds. 

January 25th: She has continued regular treatment. Took to-day 
hip bath, 85° F. for seven minutes, followed by jet douche. Her weight 
is 113 \ pounds, a gain of 6 \ pounds. Her complexion is good ; appear- 
ance bright; mental condition decidedly improved. There was a linger- 
ing degree of dissatisfaction, but I deemed it advisable to send her home 
with the injunction to her husband to insist upon occupation. 

June 8th : Frequent reports have reached me stating that Mrs. — is 
a changed being ; she is cheerful, active, and " the life of the house." 

Case II. — Neurasthenia Gastrica — Home Treatment. — Miss W., 
daughter of an Ohio physician, aged twenty-three years, was referred 
by Dr. Frank H. Bosworth, the well-known rhinologist. Pale, emaci- 
ated, despondent, the picture of woe and despair, she was brought into 
my office by her sister. She had been ill three years ; suffering first from 
fainting fits at the menstrual period; afterwards from violent pains in 
the right hand, traversing the body and concentrating in the epigas- 
trium. For these her father (a physician) has been compelled to admin- 
ister morphin for a month. Her stomach became irritable and had con- 
tinued so up to the present time; she vomited and spat up nearly all 
her food, mostly the solids. Sea baths did not improve her. She studied 
hard and grew worse. She lived on milk and farinaceous mush, and her 
stomach was regularly irrigated without improvement. 

She grew worse, became emaciated; she took peptonized milk for a 

month but vomited it; meat produced the same effect. She now lived 

on grapes, which agreed with her; had tonics, pepsin, and all possible 

medication which her father and brother could muster, without avail. 

23 



336 DISORDERS OF THE NERVOUS SYSTEM 

She was sent to Dr. Bosworth, who is a friend of her brother. After 
she had been in the city three weeks without improvement, the doctor 
sent her to me. She now vomited every day. She traced her ailments 
to painting lessons, but I drew from her the history of a potent psychical 
factor as a cause, in the sudden violent insanity of the favored nurse 
of her childhood which occurred just previous to her attack. The stom- 
ach was washed out twice a week to remove mucus and fermenting 
material, which were not abundant and ceased after a few irrigations. 
She received general faradization daily, and every morning she was 
treated with the dripping sheet at 60° F., while standing in warm water, 
with three effusions of 50° F. upon the sheet, after which she was well 
dried and sent into the open air. Under this systematic management 
she improved slowly; vomiting ceased entirely; she went to the seaside 
greatly improved. On her homeward journey she called to tell me that 
she had grown stout and felt perfectly well. Two years later she wrote 
me that despite reverses which necessitated her adopting teaching as a 
means of livelihood, her health had remained perfect, and that I would 
scarcely recognize her as the same person. 

These case histories demonstrate the importance of having the 
patient in an institution where the influences of environment, etc., 
can be regulated and controlled. They demonstrate also the fact 
that the principles of treatment outlined for hysteria apply here 
also, hence we simply refer the reader to that section. 



Neuralgia 

Neuralgia may be treated by the peripheral stimulation of the 
suffering fibers or by the depression of the sensorium. The former 
is brought about by the application of heat, electricity, or blisters 
to produce a local hyperemia; the latter is sought by giving the 
coal-tar analgesics, morphin, or the bromids. A third method is 
the blocking of the nerve trunk by injecting alcohol, salt solution, 
etc., as has been already described with reference to sciatica. Still 
another treatment for obstinate neuralgia is the pulling out of the 
entire nerve, as is most frequently done in case of trifacial 
neuralgia. 

A favorite prescription for the temporary neuralgia that may 
be relieved by analgesics is the following, because its relief seems 
more lasting than that from the ordinary analgesics: 



NEUROSES 337 

IJ Quininse bisulphatis 0.4 

Sodii bromidi 1.0 

M. f. chart, no. I. Da tales doses no. III. Sig. Dissolve one 
powder in two ounces of hot water and drink. Repeat in one hour, 
if needed. 

The value of this prescription lies in its general nerve-depressant 
power, thus reducing the response to irritation rather than pro- 
ducing a feeling of relief by simply depressing the sensorium. 

Intercostal neuralgia usually demands a course of treatment 
with the hot-air cabinet or some similar means of producing a local 
hyperemia of the thorax coupled with diaphoresis. 

In general, it is wise to treat the patient suffering from neural- 
gia of any sort by complete rest. Next it is wise to keep the air 
of the room uniform and nonirritant, because of the dangers from 
changes of temperature or draughts. Then, too, elimination should 
be thoroughly carried out both through the bowels and kidneys. 

Thus a prescription for a subacute neuralgia would assume the 
following type: 

IJ Magnesii sulphatis 10.0 

Acetphenetidini 0.3 

Potassii iodidi 0.5 

M. f. chart, no. I. Dissolve in four ounces of hot water and 
drink. 

Later it would be well to substitute a salicylate for the acet- 
phenetidin (in a dose of 0.5 to 1.0) and let the patient use it regu- 
larly three times a day for a week, preferably on an empty stomach. 

Neuritis 

Neuralgia is to be distinguished from neuritis by the fact that 
in the latter we have an inflammation of the peripheral nerve, 
while in the former we have only the peripheral pain; the lesion 
may be central or even elsewhere in the periphery. 

Neuritis requires, first of all, rest. No massage or osteopathic 
treatment should be permitted until the inflammation has been 
reduced. Then massage (very gentle friction at first) and weak 



338 DISORDERS OF THE NERVOUS SYSTEM 

electric currents will hasten the cure. At first the limb should be 
laid gently in warm sand bags, to secure the benefits of rest and 
hyperemia. Only quite late in the disease should passive move- 
ments and cold rubs be employed. 

The salicylates are used in quite heavy doses in the beginning 
to quiet the pain and bring an end to the inflammation. Sodium 
salicylate in gram doses or aspirin in half-gram doses should be 
given every two hours until the patient feels relief or the ears 
begin to ring. If the stomach will not tolerate the salicylates, 
guaiacol and methyl salicylate should be applied externally along 
the course of the nerve and driven in by heat or by an impermeable 
bandage. 

Following the salicylates, the iodids may be used with good 
effect. Thus potassium iodid, in ten- to fifteen-drop doses of the 
saturated solution, or ten drops of Donovan's solution (to secure 
an additional effect from the arsenic), should be given three times 
a day. 

Of course the elimination of waste products through bowel and 
kidney should be carefully attended to. 

Beri-beri is essentially a multiple neuritis, and as such is treated 
according to the above principles. The salicylates are given as 
noted above, at the same time heart tonics and general stimulants, 
until the system begins to respond. The bowels should be kept free. 

Prophylactically one can do much by using a diet rich in ni- 
trogenous elements (Osier) whenever one has to live in a sus- 
pected neighborhood. The Japanese secured good results in their 
navy by forbidding the consumption of raw fish. 

In addition to the simpler neuritides considered above, we have 
several forms of toxic neuritis, such as the alcoholic, the arsenical, 
that following infectious diseases, etc. The treatment is, however, 
essentially the same : rest in bed, elimination, the giving of the sali- 
cylates and analgesics, aud later the use of massage and electricity 
(here faradic or interrupted current instead of the galvanic is 
used). 



CHAPTER VIII 

DISORDERS OF THE GLANDS 

THE LYMPHATIC GLANDS 

Acute Lymphadenitis. — Acute lymphadenitis is usually confined 
to the cervical glands. Its treatment requires the correction of 
gastrointestinal disturbances, the stimulation of the skin reaction, 
and the local application of guaiacol or iodin. 

We therefore prescribe calomel in sufficient strength to keep 
the bowels active. We order cold rubs of the chest, neck, and 
back twice a day. A fifty-per-cent oil solution of guaiacol is 
rubbed into the glands every four hours. After the tenderness 
has moderated we use iodin (ten per cent in saponated petrolatum) 
rubbed in twice a day. The patient should sleep in a room with 
the windows wide open, so that he breathe pure cold air. The 
food should be bland and nourishing, but should not be in great 
variety or quantity. 

Pseudoleukemia, or Lymphatic Anemia (Hodgkin's disease). — 
Pseudoleukemia does not call for the operative removal of the 
swollen glands unless done in the very earliest stages of the dis- 
ease. On the other hand, the use of the X-ray seems to have a 
very beneficial effect on the course of the leukemia. So, also, does 
the administration of large doses of arsenic (hypodermically, as 
arsacetin). 

Hence the treatment is chiefly symptomatic and means the con- 
trol of all the patient's activities in order to increase his strength 
and vigor. 

Syphilitic and Venereal Buboes. — Syphilitic and venereal buboes 
require a line of treatment that shall both disinfect, if possible, the 
contents of the glands and provide a stimulant to the regeneration 
of the glandular walls. The pain of this type of swollen glands is 
very slight and is usually relieved by the general treatment for 

339 



340 DISORDERS OF THE GLANDS 

the condition. The drug used must be one that will be readily 
absorbed through the skin, and which, when absorbed, will pro- 
duce a local analgesic as well as a stimulant effect. Probably 
guaiacol, since it is both antiseptic and analgesic, rubbed on in 
the form of a fifty-per-cent oil solution, meets these conditions 
best. The inunction should occur several times a day. Phenolated 
camphor is also sometimes effective. Very resistant buboes usu- 
ally yield to the X-ray. The application of chloral hydrate has 
been tried for many years, but is rarely successful. Sometimes a 
solution of iodin (five to ten per cent) in saponated petrolatum x 
may be successful when well rubbed in. This vehicle is necessary 
for iodin, because in order to be at all useful the drug should not 
confine its action to the superficial layers of the epidermis, but 
must reach the glands; hence the ordinary tincture of iodin is 
well-nigh useless. 

The use of mercurial ointment is not without effect, but, since 
it is not analgesic, and, on the other hand, is dirty, it is not a 
popular remedy. 

The application of heat by means of cloths wrung out in hot 
water or of the thermophore will do much to bring about a re- 
generation of the glands. 

Tuberculous Glands. — Tuberculous glands (scrofula) demand 
first of all the constitutional treatment that is usually afforded to 
consumption. The patient should live in the open air and his 
digestion and excretion should be thoroughly stimulated, as out- 
lined in the therapeutics of consumption. In addition, the appli- 
cation of the sunlight directly to the glandular surfaces will be 
found very helpful, wherever it is not possible to extirpate the 
glands completely. For this purpose the patient should lie (with 
the face covered with a white cloth, if necessary) on a couch so 
as to permit the direct sunlight to reach the glands. The most 
successful treatment, therefore, is to be found in those climates 
where the sun is bright and not hidden by frequent clouds. Some- 
times the same effect as that produced by sunlight, that is, that 

1 Saponated petrolatum — formula : 

Liquid petrolatum 60 . 

Oleic acid 30.0 

Spts. ammonia 15 . 



THE SPLEEN 341 

obtained by the passage of a strong galvanic current through the 
glands, will be found to check their growth. Thus the positive 
electrode, with a gold or platino-iridium needle, thrust into the 
glands electrolizes much of the pathological material. The strength 
of the current should be about thirty milliamperes. The guaiacol 
inunctions mentioned for acute lymphadenitis may be used here 
also ; but whatever the treatment employed, it should be remem- 
bered that the primary object is the strengthening of the con- 
stitution of the patient, and that the local treatment will be 
successful only when the bodily resistance to tuberculosis will be 
strong enough so that the disease cannot invade any other part 
of the body. This same principle applies when one discusses the 
matter of extirpation, because extirpation is useless unless the 
bodily resistance be raised ; therefore it is generally wise to insti- 
tute the correct hygienic treatment, and then, having increased 
the patient's weight and raised his resistance, remove the inflamed 
glands. 

THE SPLEEN 

Splenomegaly. — This may result from chronic malaria or may 
be the accompaniment of some of the leukemias or pseudoleuke- 
mias. Quinin has been noted for a long time for its power to 
reduce the size of the spleen. Methylene blue has a similar effect. 
But any treatment directed toward relieving the condition must 
take into consideration the constitutional results necessary to bring 
about such a change, because splenomegaly is only a symptom and 
does not constitute the entire disease. 

Arsenic to stimulate the formation of red corpuscles in the 
bone marrow is probably the most used drug for splenomegaly, 
and, in order to avoid injuring the stomach, is now being given 
hypodermically in the form of arsacetin (twenty-five minims of the 
ten-per-cent solution on alternate days). The X-ray applied for 
ten minutes on alternate days will also have a beneficial effect in 
decreasing the size of the spleen. 

The patient should, of course, be kept quiet and the diet regu- 
lated. This is the more necessary because in most of the conditions 
accompanied by splenomegaly there is a hyperemia of the mucosa 
of the stomach and intestines, and this in turn produces indiges- 
tion. The use of dilute hydrochloric acid to overcome this indi- 



342 DISORDERS OF THE GLANDS 

gestion and of cathartics to keep the bowels in order is therefore 
usually necessary. 

THE ADRENAL BODIES 

The most common disease of the adrenal bodies seems to be 
tuberculosis. Aside from this we find ordinarily only a nonspecific 
interstitial inflammation. 

The most prominent symptoms are due to the loss to the body 
of the normal secretion; therefore the primary indication is to 
supply to the body secretions thus lost to it. As for attacking the 
process in the glands, very little can be accomplished, hence the 
treatment is one of general constitutional stimulation plus the ad- 
ministration of adrenal extract. 

The glandular extracts, when given for such a purpose as this, 
should always be used when the stomach is empty and there is 
little danger of their being broken up by the gastric juices. Prob- 
ably the crude adrenal extract for such conditions would be better 
than adrenalin or any one of the active principles. The dose varies 
from two to five grains a day, given in water, about two hours from 
mealtime. 

THE PITUITARY BODY 

In two cases of exophthalmic goiter treated by me with pituitary sub- 
stance both were relieved of tachycardia, nervous distress, and headache. 
In a psychosis that looked much like catatonia, in which both physical 
and mental decay had progressed apparently to the limit, the ingestion 
of this agent resulted in complete mental restoration and fairly good 
physical vigor. This case also had most intense vasomotor spasm, with 
hot flashes, that had previously resisted suprarenal treatment. These 
waves of heat and redness both ceased after exhibition of pituitary 
substance. 

In a case with endocardial, myocardial, and vascular changes due 
to an arteriosclerosis in a woman of seventy years of age, in whom the 
pulse was more than 130 and the eyes protruded and great distress ex- 
isted, six grains of the substance lowered the beats to 90 and gave much 
comfort. A case with mitral regurgitant and aortic obstructive mur- 
murs, with a pulse rate of 120, received one cubic centimeter of the 
extract from the posterior lobe of the pituitary gland. In twenty-four 
hours the pulse rate was 80, and the patient in a week's time showed 



THE THYROID GLAND 343 

marked strength and tone in the cardiac action. In several cases of 
irregular heart action, attended with a feeling of oppression, much com- 
fort has been observed following the use of the gland substance. 

In a case of conjunctivitis, caused by a cinder, the extract of the 
posterior portion dropped on the congested surface could be seen to 
contract the blood vessels quite rapidly. (R. A. Bate, M.D., American 
Practitioner and News, March, 1909.) 

To be sure of getting a prime quality I applied to Parke, Davis & 
Co., who kindly placed at my disposal a pure and uniformly potent 
preparation. I found that the extract produces first a slight lowering 
of the blood pressure, and then gradually a marked increase. A renal 
turgescence usually followed the intravenous injection of pituitary ex- 
tract in dogs, cats, and rabbits. This was registered on the oncometer, 
and there was, as a rule, certain parallelism between its curve and that 
of the blood pressure. In the case of cats the diuretic effect of the 
extract after intravenous administration was marked. I emptied the 
bladder of a cat to which morphin and curara had been given, and noted 
that the viscus was refilled in a very short time after the injection of 
two centimeters of the extract. When emptied the second time, the 
organ was again rapidly refilled. In experiments on the extirpated 
arteries of cattle — the coronary, carotid, and femoral arteries — I found 
that a contraction takes place ; but in the case of the renal artery (periph- 
eral section) there is relaxation. A mydriatic effect is produced on the 
extirpated eye of the frog. 

These quotations show the trend of thought regarding the in- 
fluence of the pituitary body, hence in diseases of that gland (e. g., 
genital infantilism) we need to supply pituitary extract, and also 
use such general constitutional treatment as shall best keep the 
patient in good general health (i.e., symptomatic treatment). 

Bell (British Medical Journal, December 4, 1909) has used in- 
fundibular extract 1 in 1 c.c. doses with good results in postpartum 
hemorrhage, in intestinal paralysis, and in local conditions re- 
quiring a great rise in blood pressure. 

THE THYROID GLAND 

There are two types of pathological conditions connected with 
diseases of the thyroid gland. The first is an increase in the 

1 Prepared by Burroughs, Wellcome & Co., of London. 



344 DISORDERS OF THE GLANDS 

secretion of the gland producing nervous tremor, exophthalmos, 
etc., and the other is a decreased secretion of the gland producing 
thyroid myxedema, thickening of the skin, etc. The first is called 
hyperthyroidism and is a characteristic of Graves's disease; the 
second is hypothyroidism and is a characteristic of cretinism. 

In the former case measures must be taken, if possible, to de- 
crease the activity of the gland and to neutralize the effect of the 
excessive secretion. The first is usually accomplished by surgical 
means, the second by giving drugs that will antagonize the action 
of the thyroidin in the nervous system. Some good effects have 
been reported for this latter purpose by using thyroidectin, that 
is, the serum of thyroidectomized goats. The sedation of the sym- 
pathetic Aervous system may also be accomplished sometimes by 
the use of aconite (four drops of the tincture three times a day). 
Again, the tincture of digitalis to quiet the heart may be useful. 
But, in general, the best we can do will be to watch the individual 
symptoms day by day and counteract them by the appropriate 
drugs as they arise. Probably no two patients would require the 
same drugs. 

Forchheimer (pp. 434 et seq.) advises the routine administra- 
tion of quinin hydrobromate in doses of 0.3 gm. (gr. v) in gela- 
tin-coated pills four times a day. He adds ergotin, 0.065 gm. 
(gr. j), if the quinin does not show good results in forty-eight 
hours. 

In case of hypothyroidism (cretinism or myxedema) the ex- 
tract of the thyroid gland should be administered. The dose will 
vary from two to five grains pro die. It should be given on an 
empty stomach with water and under conditions that prevent its 
being broken up by the gastric juices. 

An interesting study of endemic goiter has been published by 
Robert McHarrison in the Quarterly Journal of Medicine for 
April, 1909. Herein the conclusion is reached that endemic goiter 
is due to living organisms taken in with the drinking water. Cures 
were effected by the use of intestinal antiseptics. For this pur- 
pose powdered thymol (ten grains night and morning) seemed 
particularly effective. 



CHAPTER IX 

DISORDERS OF METABOLISM 

GOUT 

Gout is evidently due to the inability of the excretory organs 
to free the body of the waste nitrogenous compounds. This may 
be due to an excessive supply of such bodies, or to a weakening 
of the excretory apparatus, or both; hence we find the disease in 
those who eat as if woodchoppers and yet live sedentary lives, and 
also in those who live in the cold and damp, thus inhibiting the 
excretory processes. 

Its causal treatment, therefore, consists in adjusting the pa- 
tient's life so that his food shall equal his ability to consume and 
excrete. To do this the excretory power of the kidneys should be 
studied day after day on diets containing various amounts of ni- 
trogen — measuring the urine and its contained nitrogen — until 
we find the limits of renal toleration. 

In some cases it would be necessary to raise the patient's mus- 
cular work in order to secure a complete combustion of the food 
consumed. 

In other cases it will be necessary to restrict the diet, limiting 
the meat and insisting upon a thorough mastication of the food 
taken. Alcohol and similar stimulants need to be prohibited in 
all gouty subjects. 

The symptomatic treatment of an attack follows the general 
lines. The painful joint is raised to a level with the rest of the 
body, anointed freely with guaiacol (fifty per cent in olive oil) 
and swathed in impermeable bandages. Morphin (J grain) or 
colchicin (-fa grain) is given hypodermically, and as soon as the 
patient's condition permits a free catharsis (calomel or salts) is 
brought about. The use of hot baths and massage to secure the 
absorption of the exudates is next in order. 

345 



346 DISORDERS OP METABOLISM 

As an illustrative dietary for a gouty subject we give here that 
of Porchheimer : 

Breakfast — Small cup black coffee, two eggs, crisp fried or 
broiled bacon, toast, fruit. 

Luncheon — Fish, oysters, vegetables, fruit, milk, bread. 
Dinner — Meat, vegetables, salad, fruit, bread. 



ARTHRITIS 

Inflammations of the joints are still very properly called 
" rheumatic," because we know nothing surely about their etiol- 
ogy and pathogenesis, hence the treatment is still empirical and 
symptomatic. 

Of the two chief theories on which methods of treatment are 
based, the one implies that the disorder is essentially an acidosis 
of the body fluids, the other that it is an infectious process; there- 
fore adherents of the former belief give alkalies in great quantity, 
those of the latter coal-tar antiseptics. The former theory suf- 
fered greatly in the downfall of the humoral pathology and in 
the rise of the cellular pathology and the germ theory of disease, 
but of late has secured added strength because the treatment based 
on it has seemed to succeed in cases where the salicylates and other 
coal tars have failed to cure. 

In general, then, we must admit that we have no specific or 
causal remedy for rheumatism, and must treat it essentially along 
symptomatic lines. 

The pain of the acute febrile arthritis requires immobilizing 
the joints and the application of heat. Thus we pack the joint in 
hot sand bags, or prop it up with soft pillows and apply the 
thermophore. 

The swelling and tenderness are greatly benefited by the in- 
unction of methyl salicylate (oil of wintergreen) in twenty -five- 
to fifty-per-cent olive-oil solution and then wrapping the joint 
with bandages of flannel or absorbent cotton, and covering with 
waxed paper or oiled silk to retain the heat. Or, if a thermophore 
is to be used, the oil may be applied gently directly to the skin and 
the light then turned on without the bandage. 

The systemic condition is most quickly influenced by giving 



ARTHRITIS 347 

sodium salicylate in one-gram (fifteen grains) doses every two 
hours for eight doses. This should be discontinued sooner if the 
patient complains of ringing in the ears. 

When the patient cannot take sodium salicylate alone in pow- 
ders or capsules, we may sometimes succeed in giving it as a part 
of an effervescing mixture/ or we may Tiave to turn to acetphene- 
tidin or the other coal-tar analgesics. These have to be given in 
full doses and at frequent intervals to keep down the pain until 
the local treatment shall have had time to relieve it. 

When the condition has become more or less chronic we bring 
into play local hyperemia. For this we use by preference the 
local application of dry hot air for about forty-five minutes each 
day. The vacuum apparatus, when at hand, is also useful, but 
the latter is more often used for ankylosis than for the inflamma- 
tion itself; that is, it is specially adapted for assisting in bringing 
about a renewal of joint motion after the inflammation is past. 

During the fever of acute arthritis we must have the patient 
wear a bed gown or pyjamas of absorbent material, in order to 
avoid the discomfort from the clammy sweat and the real danger 
of his becoming chilled by his moist clothing. Alkaline washes 
(sodium-bicarbonate solution) sometimes assist in keeping the skin 
free from moisture and irritation. The skin of the groins and 
elsewhere where excoriations are liable to occur should be kept 
covered with a soothing powder (e.g., talcum). 

The diet needs to be very nutritious, although very digestible, 
for the patient develops rapidly an anemia if not kept to the 
highest point of nutrition. 

1 Formula A (National Formulary). Fine Powder. 

Sodium salicylate, in fine powder 50 parts 

Saccharated sodium bicarbonate (N. F.) 475 " 

Saccharated tartaric acid (N. F.) 475 " 

Formula B. Granular Powder. 

Sodium salicylate in fine powder 50 parts 

Saccharated sodium bicarbonate (N. F.) 475 " 

Saccharated tartaric acid (N. F.) 237 . 5 " 

Saccharated citric acid (N. F.) 237 . 5 " 

One heaping teaspoonful equals about 0.3 gram or 5 grains. 

This powder will not entirely dissolve, but if taken while effervescing will 
carry the insoluble material along with the fluid. 



348 DISORDERS OF METABOLISM 

To guard against the endocarditis, which arthritis often brings 
on, all patients suffering from inflammatory rheumatism must be 
kept from moving more than absolutely necessary, even though the 
attack seem very light. When the heart murmur is detected an 
ice bag should be applied to the chest at once and the regimen for 
heart disease instituted. 

The alkaline treatment referred to above calls for sufficient 
alkalies of one sort or another to keep the urine alkaline. Sodium 
and potassium citrate (1 to 2 grams every hour) are the favor- 
ite forms. 

But Garrod gave twenty grains of potassium bicarbonate every 
three to four hours, night and day, together with heavy doses of 
quinin, until the temperature dropped. Another variation is that 
of Puller, who dissolved ninety grains of sodium bicarbonate and 
thirty grains of potassium acetate in three ounces of water and 
added one ounce of lemon juice to render it effervescent. This was 
continued until the urine became alkaline. 

A compromise between the salicylate and alkaline methods is 
obtained by using doses of twenty grains of sodium salicylate and 
thirty grains of potassium bicarbonate, dissolved in two ounces of 
water, every two or three hours. This may be made effervescent 
by adding lemon juice or twenty grains of citric acid. When the 
temperature falls the dose of salicylate should be decreased to ten 
grains, and when the urine becomes alkaline the mixture should 
be given at longer intervals (Yeo). 

In obstinate cases of rheumatism bathing in hot sulphur water 
has given good results. But in default of the opportunity to give 
these the use of the hot-air cabinet or the electric-light bath will 
show improvement worth while. The most popular sulphur baths 
are those at Mt. Clemens, Mich., and Hot Springs, Ark. 

Massage and passive exercises, carefully regulated, are also 
beneficial. The physician should prescribe these as carefully as 
he does his drugs to see that the most good is done, or at least that 
no damage is done on account of ignorant zeal. 

Arthritis deformans must be treated along the lines of chronic 
rheumatism. In addition, the use of electricity and heavy doses 
of arsenic (e. g., arsacetin intramuscularly) will be needed to check 
the progress of the disorder. This is a matter of months; there- 
fore institutional treatment is advisable. Such treatment should 



DIABETES MELLITUS 349 

include baths, passive movements, high-frequency currents, pleas- 
ant surroundings, and arsenic. 

DIABETES MELLITUS 

The problem of the treatment of diabetes mellitus will not be 
solved until we know more of its etiology. We know that it may 
be due to lesions in the pancreatic gland and also to lesions in the 
medulla. We believe that it may be caused also by exhausting 
the tolerance of the organism for sugar either by overindulgence 
in the ingestion of sugar or by some inefficiency in the work of 
the liver. We do not know the interaction between the thyroid 
and the pancreas well enough to evaluate the influence of the for- 
mer gland in glycosuria. 

Hence practically our present line of treatment is simply to 
raise the tolerance of the organism for sugars. This we seek to do 
by ascertaining the amount of carbohydrates any given patient 
may ingest without glycosuria, and then, by increasing the vigor 
of his body and carefully regulating the amount of carbohydrates 
in his food, seek to increase gradually the limit of tolerance until 
the patient may live a relatively normal life without glycosuria. 

The use of drugs, except to relieve particular symptoms, has 
been disappointing. This includes the opiates as well as the vari- 
ous glandular preparations, hence the drug treatment is practi- 
cally confined to the treatment of symptoms. The following items 
will serve as illustrations: 

The itching is usually relieved by simple local applications 
and by hot baths and massage to raise the skin resistance. In con- 
nection with such hot baths (e. g., the use of the hot-air cabinet) 
daily rubs should be taken with cold water. If vesicles and sores 
appear on the skin a dusting powder of calomel (ten per cent) 
and starch is usually sufficient to heal them if the systemic re- 
sistance can be raised. For the pruritus itself a menthol ointment 
(see Pruritus) is usually sufficient until the care of the skin brings 
about an improvement. 

The constipation is best relieved by the use of phenolphthalein 
with pancreatin and papain, the purpose being to stimulate in- 
creased peristalsis and at the same time an increased digestion of 
the food. Thus a capsule made up of one half to one grain of 



350 



DISORDERS OF METABOLISM 



phenolphthalein, two grains of pancreatin, and two grains of 
papain should be given two hours after meals. 

The thirst is relieved by the use of lemonade or other acidu- 
lated drink. 

The diet basis is meat, fats, and green vegetables. We must, 
of course, supply at least 2,000 calories of heat energy, and the 
animal economy will not permit us to supply this exclusively of 
protein. We may use fats freely up to the point where their pres- 
ence obstructs digestion. The accompanying tables, from the Bul- 
letins of the Agricultural Department of the United States Govern- 
ment, show the content of the various foodstuffs in carbohydrates: 

Table I 
Composition of Food Materials, Edible Portion 



Food Materials. 



average 



Meats, etc. 
Beef: 

Neck 

Chuck ribs " 

Ribs " 

Brisket 

Cross ribs 

Shoulder average 

Shin 

Plate 

Navel 

Sirloin average 

Socket 

Rump average 

Round " 

Leg 

Top of sirloin .■ 

Flank 

Fore quarter 

Hind quarter 

Side without kidney fat 

Liver 

Kidney 

Heart 

Tongue 

Kidney fat 

Marrow (leg bone) 



Veal: 

Shoulder. 



average 



Per 
cent. 

62.0 
58.0 
48.1 
47.4 
43.9 
63.9 
73.8 
44.4 
47.6 
60.0 
57.1 
48.2 
68.2 
72.1 
42.2 
27.4 
54.1 
55.7 
54.8 



Nutrients. 



Per 

cent. 

38.0 

42.0 

51.9 

52.6 

56 

36 

26 

55 

52 

40.0 

42.9 

51.8 

31.8 

27.9 

57.8 

72.6 

45.9 

44.3 

45 

30 

24 

43 

36 



68.831.220.2 



Per 
cent, 



Per 

cent. 

17.5 
23.5 
35.6 
37.2 
41.6 
15.6 

2.3 
39.4 
36.5 
20.5 
25.2 
35.6 
10.1 

5.7 
43.7 
59.9 
27.7 
26.3 
27.1 

5.4 

4.8 
26.2 
18.0 
94.6 
92.8 



9.8 



Per 

cent 



sa 



Per 

cent 

1.0 

0.9 
0.9 
0.8 
0.8 
1.0 
1.2 
0.8 
0.8 
1.0 
1.0 
0.8 
1.2 
1.2 
0.8 
0.7 
0.9 
0.9 
0.9 
1.5 
1.2 
1.0 
1.1 
0.2 
1.3 



1.2 



»T3 

> a 

— <v 

a a 
P o 



Calo- 
ries. 

1,100 
1,320 
1,790 
1,840 
2,010 
1,020 
520 
1,950 
1,820 
1,210 
1,375 
1,790 
805 
630 
2,090 
2,750 
1,490 
1,430 
1,465 
665 
545 
1,410 
1,085 
4,010 
3,965 



790 



DIABETES MELLITUS 



351 



Table I. — Composition of Food Materials, Edible Portion — (Continued) 



Food Materials. 



Nutrients. 



'- - 









Meats, etc. — (Continued) 
Mutton: 

Shoulder 

Breast 

Rack 

Neck 

Leg 

Loin 

Flank 

Fore quarter 

Hind quarter 

Side without kidney fat 



Lamb: 

Shoulder 

Breast 

Neck 

Leg 

Loin 

Fore quarter 

Hind quarter 

Side without kidney fat. 

Liver 

Heart 

Lungs 



Pork: 

Shoulder roast . 



average 



Poultry, etc.: 

Chicken 

Chicken liver 

Chicken heart 

Chicken gizzard 

Turkey 

Turkey liver 

Turkey heart 

Turkey gizzard 

Hen's eggs in shell average 

Preserved Meats: 

Corned beef, rump 

Corned beef, flank average 

Corned beef, canned " 

Dried beef " 

Tripe, soused 

Salt pork, fat 

Smoked ham 

Pork sausage average 

Bologna sausage 

24 



Per 

cent. 

58.6 



Per 

cent. 

41.1 



37.662.4 
54.9|45.1 
55.7 44.3 
61.838.2 
49.3>50.7 



38.7 
55.2 
54.7 
53.5 



51.8 
56.2 
56.7 
64.7 
54.8 
55.1 
60.9 
57.9 
52.7 
67.4 
74.6 



50.3 



72.2 
69.3 
72.0 
72.5 
66.2 
69.6 
68.6 
62.7 
73.8 



58.1 
49.8 
52.8 
58.6 
84.0 
12.1 
41.5 
41.2 
62.4 



61.3 

47.8 
45.3 
46.5 



48.2 
43.8 
43.3 
35.3 
45.2 
44.9 
39.1 
42.1 
47.3 
32.6 
25.4 



49.7 



41.9 
50.2 
47.2 
41.4 
16.0 
87.9 
58 5 
58.8 
37.6 



Per 

cent. 

18.1 
14.2 
18.4 
16.2 
18.3 
15.0 
15.8 
17.0 
16.9 
16.9 



17.5 
19.2 
17.5 
18.9 
19.0 
18.1 
18.9 
18.6 
24.2 
18.3 
21.5 



16.0 



24.4 
22.3 
21.2 

24.7 
23.9 
22.9 
17.2 
21.7 
14.9 



Per 

cent 

22.4 
47.2 
25.9 
27.3 
19.0 
35.0 
45.0 
29.9 
27.5 
28.7 



29 
23 

24.8 
15.3 
25.1 
25.8 
19.1 
22.5 
13.2 
13.4 
2.6 



32 



2.0 

4.2 

5.4 

1.4 

8.7 

5.2 

13.2 

14.5 

10.5 



26.6 

33.0 

17.1 

4.4 

1.8 
82.8 
39.1 
42.8 
15.8 



Per 
cent 



Per 

cent. 

0.9 
1.0 

0.8 

0.8 

0.9 



0.5 

0.9 

0.9 

0.9 



0.9 



1.4 
1.8 
1.4 
1.4 
1.2 
1.7 
1.0 



0.8 



2.0 
3.0 
3.4 

6.8 
0.3 
4.2 
2.7 
2.2 
3.0 



Calo- 
ries. 

1,280 
2,255 
1,435 
1,455 
1,140 
1,755 
2,195 
1,580 
1,475 
1,525 



1,580 
1,355 
1,375 
1,000 
1.410 
M25 
1,155 
1,295 
1,155 
905 
510 



1,680 



540 
635 
620 
520 
810 
655 
875 
1,015 
720 



1,370 
1,655 
1,220 
745 
335 
3,510 
1,960 
2,065 
1,015 



352 



DISORDERS OF METABOLISM 



Table I. — Composition of Food Materials, Edible Portion — (Continued) 



Food Materials. 



Fish, Shellfish, etc. 
Fresh Fish: 

Sturgeon 

Red horse 

Herring 

Alewif e average 

Shad " 

Smelt " 

Whitefish 

Cisco 

California salmon average 

Salmon " 

Lake trout " 

Brook trout " 

Pickerel " 

Pickerel, pike 

Muscalonge 

Eel, salt water average 

Mullet 

Mackerel average 

Spanish mackerel 

Pompano 

Bluefish 

Butterfish 

Black bass average 

Yellow perch " 

Wall-eyed pike 

Gray pike 

Striped bass 

White perch average 

Sea bass 

Grouper average 

Red snapper " 

Porgy 

Sheepshead " 

Red bass 

Kingfish 

Weakfish 

Blackfish average 

Hake 

Cusk 

Haddock average 

Cod " 

Tomcod 

Pollock 

Halibut average 

Turbot 

Flounder average 

Lamprey eel 

Skate 



Per 

cent. 

78.7 

78.6 

69.0 

74.4 

70.6 

79.2 

69.8 

76.1 

63.6 

63.6 

69.1 

77.7 

79.7 

79.8 

76.3 

71.6 

74.9 

73.4 

68.1 

72.8 

78.5 

70.0 

76.7 

79.3 

79.7 

80.8 

77.7 

75.7 

79.3 

79.4 

78.5 

75.0 

75.6 

81.6 

79.2 

79.0 

79.1 

83.1 

82.0 

81.7 

82.6 

81.5 

76.0 

75.4 

71.4 

84.2 

71.1 

82.2 



Nutrients. 



Per 
cent 

21.3 
21.4 
31.0 
25.6 
29.4 
20.8 
30 2 
23.9 



Per 
cent 

18.0 

17.9 
18.5 
19.2 
18.6 
17.3 
22.1 
19.1 
17.4 



Per 

cent. 

1.9 

2.3 

11.0 

4.9 
9.5 
1.8 
6.5 
3.6 
17.9 



21.6.13.4 
18.211.4 



19.0 
18.6 
18.6 
19.6 
19.3 
19.3 



>> . 

-Pa 



Per 
cent 



26.6 18.2 



31.9 
27.2 
21.5 
30.0 
23.3 
20.7 
20.3 
19.2 
22.3 
24.3 
20.7 
20.6 
21.5 
25.0 
24.4 
18.4 
20.8 
21.0 
20.9 
16.9 
18.0 
18.3 
17.4 
18.5 
24.0 
24.6 
28.6 
15.8 
28.9 
17.8 



20.6 

18.6 

19.0 

17 

20.4 

18.7 

18.4 

17.3 

18.3 

19.0 

18.8 

18.9 

19.2 

18.5 

19.5 

16.7 

18.7 

17.4 

18.5 

15.2 

16.9 

16.8 

15.8 

17.1 

21.7 

18.3 



2.1 
0.5| 



0.6 
2.5 
9.1 
4.6 
7.1 



7.6 

1.2 

11.0 

1.7 

0.8 
0.5 
0.8 
2.8 
4.1 
0.5 
0.6 
1.0 
5.1 
3.7 
0.5 
0.9 
2.4 
1.3 
0.7 
0.2 
0.3 
0.4 
0.4 
0.8 
5.2 



12.914.4 
13. 9j 0.6 
14.9 13.3 
15.31 1.4 



^S 



Per 

cent 

1.4 

1.2 

1.5 

1.5 

1.3 

1.7 

1. 

1.2 

1.1 

1.4 

1.3 

1.3 

1.2 

1.0 

1.6 



1 
1 
1 
1 
1.0 
1.3 
1.2 
1.2 
1.2 
1.4 
1 



W T3 
cS O 



1 

1 

1 

1 

1 

1.3 

1.4 

1.2 

1.2 

1.2 

1.2 

1.1 

1.0 

0.9 

1.2 

1.2 

1.0 

1.5 

1.1 

1.3 

1.3 

0.7 

1.1 



Calo- 
ries. 

415 

430 
810 
565 
745 
400 
685 
505 
1,080 
965 
820 
440 
365 
370 
470 
725 
555 
640 
790 
665 
405 
795 
450 
380 
365 
355 
460 
525 
370 
375 
400 
560 
520 
230 
385 
425 
400 
310 
325 
325 
310 
335 
440 
560 
850 
285 
840 
345 



DIABETES MELLITUS 



353 



Table I. — Composition of Food Materials, Edible Portion — (Continued) 



Food Materials. 



Fish, Shellfish, etc. — {Continued) 
Preserved Fish: 

Desiccated cod 

Salt cod average 

Boned cod 

Salt mackerel 

Smoked haddock 

Smoked halibut average 

Canned mackerel 

Canned salmon average 

Canned sardines 

Canned tunny 

Canned salt mackerel average 

Canned smoked haddock 



Shellfish, etc.: 

Oysters in shell average 

Oysters, "solids" " 

Canned oysters average 

Long clams from shell " 

Long clams, canned 

Round clams from shell 

Round clams, canned 

Scallops average 

Mussels from shell 

Lobster from shell average 

Lobster, canned " 

Crayfish 

Crab 

Crabs, canned average 

Shrimp 

Terrapin 

Green turtle 



Dairy Products. 

Milk 

Butter 

Cheese, full cream average 

Cheese, skim milk 

Oleomargarine 



Vegetable Foods. 

Potatoes average 

Sweet potatoes " 

Red beets " 

Turnips " 

Carrots " 

Onions " 

Squash, flesh " 

Pumpkin, flesh " 



Per 
cent. 

2.9 
23.0 
21.5 
10.6 

0.2 
12.9 

1.9 

1.0 



Per 

cent. 

15.2 
53.6 
54.3 
42.2 
72.5 
49.4 
68.2 
61.9 
56.4 
72.7 
43.4 
.7 



Nutrients. 



Per 

cent 

81.9 

23.4 

24.2 

47.2 

25 

37 

29.9 

37.1 

43.6 

27.3 

46.3 

25.7 



12.9 

12.8 

14.7 

14.2 

15.5 

13.8 

017.0 

319.7 

2,15.8 

8 18.2 

7J22.3 

2.18.8 

1122.9 

0|20.0 

8 29.2 

5 25.5 

20.2 



87.013.0 
10.589.5 
30.269.8 
41.358.7 
11.089.0 



78.921.1 
71.128.9 
88.511.5 
89.410.6 
88.611.4 
87.612.4 
88.111.9 
93.4 6.6 



Per 
cent 
74.6 
21.4 
22.2 
22.1 
23.7 
20.6 
19.9 
20.1 
25.3 
21.5 
17.3 
21.8 



6 1 
6.3 

7.4 



8.7 
14.6 
18.7 
17.0 
17.8 
16.5 
25.6 
21.0 
18.5 



3.6 
1.0 

28.3 

38.4 

0.6 



1.1 
1.4 

0.9 
0.9 



Per 

cent. 

1.9 

0.4 

0.3 
22.6 

0.2 
15.1 

8.7 
15.7 
12.7 

4.1 
26.3 

2.3 



1.2 
1.6 
2.1 
1.0 
1.3 
0.4 
0.8 
0.2 
1.1 
1.9 
1.1 
0.5 
2.0 
1.5 
1.0 
3.5 
0.5 



4.0 
85.0 
35.5 

6.8 
85.0 



0.1 
0.4 
0.1 
0.2 
0.4 
0.3 



Per 

cent 



a -» 



4.7 
0.5 
1.8 
8.9 
0.4 



17. 9i 

26. 1 
8.8 
8.2 
8.9 

10.1 



0.210.1 
O.ll 4.9 



Per 

cent. 

5.4 
1.6 
1.7 
2.5 
1.5 
2.0 
1.3 
1.3 
5.6 
1.7 
2.6 
1.6 



2.0 
0.9 
1.3 
2.6 
2.3 
2.7 
2.8 
1.4 
1.9 
1.7 
2.5 
1.3 
3.1 
2.0 
2.6 
1.0 
1.2 



0.7 
3.0 
4.2 
4.6 
3.0 



1.0 
1.0 
1.1 
1.0 
1.0 
0.6 
0.7 
0.7 






Calo- 
ries. 

1,470 
410 

425 
1,365 

450 
1,020 

735 
1,035 
1,005 

575 
1,430 

505 



230 
260 
300 
240 
275 
215 
285 
345 
285 
350 
395 
335 
415 
370 
520 
540 
365 



325 
3,615 
2,070 
1,165 

3,605 



375 
530 
195 
185 
205 
225 
215 
110 



354 



DISORDERS OF METABOLISM 



Table I. — Composition of Food Materials, Edible Portion — (Continued) 



Food Materials. 



Vegetable Foods. — (Continued) 

Cucumber average 

Cabbage, entire " 

Cabbage, inner leaves " 

Cauliflower. " 

Lettuce " 

Spinach 

Rhubarb, stems 

Asparagus average 

Tomatoes " 

Green peas j 

String beans average 

Lima beans, green 

Okra 

Green sweet corn 

Egg plant 

Peas 

Peas, canned average 

Haricots, verts, canned " 

String beans, canned " 

Stringless beans, canned " 

Haricots flageolets, canned " 

Haricots panaches, canned 

Little green beans, canned 

Wax beans, canned 

Lima beans, canned average 

Baked beans, canned " 

Red kidney beans, canned 

Corn, canned average 

Artichokes, canned " 

Sweet potato 

Okra, canned average 

Brussels sprouts, canned 

Tomatoes, canned average 

Asparagus, canned " 

Pumpkin, canned " 

Squash, canned " 

Macedoine, canned " 

Succotash, canned " 

Mixed corn and tomatoes, can'd " 
Mixed okra and tomatoes, can'd " 

Apples, flesh " 

Cherries, flesh 

Strawberries average 

Blackberries 

Whortleberries 

Cranberries 

Grapes, Catawba 

Lemons average 



Per 
cent. 

96.0 
90.5 
93.1 
90.8 
93.1 
92.4 
92.7 
94.0 
96.0 
78.1 
87.2 
68.5 
87.4 
81.2 
92.9 
83.9 
85.4 
95.1 
94.3 
93.9 
81.6 
86.1 
93.8 
94.7 
79.7 
67.2 
72.7 
75.4 
92.5 
68.4 
94.4 
93.8 
93.7 
94.4 
92.7 
86.6 
93.1 
76.2 



Nutrients. 



Per 

cent. 

4.0 

9.5 

6.9 

9.2 

6.9 

7.6 

7.3 

6.0 

4.0 

21.9 

12.8 

31.5 

12.6 

18.8 

7.1 

16.1 

14.6 

4.9 

5.7 

6.1 

18.4 

13.9 

6.2 

5.3 

20.3 

32.8 

27.3 

24.6 

7.5 

31.6 

5.6 

6.2 

6.3 

5.6 

7.3 

13.4 

6.9 

23.8 



87.512.5 



91.8 
83.2 
86.1 
90.8 
88.9 



8.2 
16.8 
13.9 

9.2 
11.1 



82.417.6 
87.612.4 
74.825.2 
89.3,10.7 



Per 
cent 

0.8 
2.4 
1.5 
1.6 
1.6 
2.1 
0.8 
1.8 
0.8 
4.4 
2.2 



7 

2 

2 

1 



3 

1 



1 

4 

3 

1 

1 

4 

7 

7 

2.8 

0.8 

1.3 

0.7 

1.5 

1.3 

1.5 

0.7 

0.5 

1.3 

3.5 

1.7 

1.2 

0.3 

1.1 

1.0 

0.9 

0.7 

0.4 

1.6 

1,0 



Per 
cent. 

0.2 
0.4 
0.2 
0.8 
0.5 
0.5 
1.2 
0.2 
0.4 
0.5 
0.4 
0.7 
0.4 
1.1 
0.3 
0.8 
0.2 
0.1 
0.1 
0.1 
0.1 

o.i 



0.2 
1.3 

0.3 
0.1 
1.0 
0.2 
0.1 
0.1 
0.3 



0.9 
0.4 
0.2 
0.4 
0.8 
0.7 
2.1 
3.0 
0.9 
1.7 
0.9 



■eg 



Per 

cent. 

2.5 

5.3 

4.6 

5.0 

3.7 

3.1 

4.4 

3.3 

2.5 

16.1 

9.5 

22.0 

9.5 

14.2 

5.1 

14.2 

9.7 

2.6 

3.5 

3.5 

12.5 

9.2 

3.4 

3.0 

14.4 

20.3 

18.5 

19.6 

5.0 

29.2 

3.6 

3.4 

4.2 

2.8 

6 

12 

4 

18 

9 

5 

15.9 

11.4 

6.9 

7.5 

13.5 

10.9 

21.3 

8.3 



£S 



Per 

cent. 

0.5 
1.4 
0.6 
0.8 
1.1 
1.9 
0.9 
0.7 
0.3 
0.9 
0.7 
1.7 
0.7 
0.7 
0.5 
0.5 
1.1 
1.1 
1.2 
1.4 
1.2 
1.0 
1.5 
1.2 
1.6 
2.2 
1.6 
0.9 
1.7 
0.8 
1.2 
1.3 
0.6 
1.2 
0.5 
0.4 
1.0 
0.9 
0.9 
1.6 
0.2 
0.6 
0.6 
0.6 
0.4 
0.2 
0.6 
0.5 



Calo- 
ries. 



DIABETES MELLITUS 



355 



Table I. — Composition of Food Materials, Edible Portion — (Continued) 



Food Materials. 



Nutrients. 



2S 



IS 



Vegetable Foods. — {Continued) 

Banana, pulp 

Pineapple 

Watermelon, flesh or pulp 

Nutmeg melon, flesh or pulp 

Rice average 

Beans, dried " 

Maize meal " 

White hominy " 

Oatmeal " 

Pearl barley 

Rye flour average 

Wheat " 

Graham flour " 

Entire wheat flour " 

Cracked wheat " 

Buckwheat flour " 

Buckwheat farina " 

Buckwheat groats 

Wheat bread average 

Graham bread 

Rye bread 

Boston crackers 

Soda crackers 

Pilot (bread) crackers 

Oyster crackers 

Oatmeal crackers 

Graham crackers 

Starch 

Sugar, granulated 

Molasses 



Per 

cent. 

66.3 

89.3 

91.9 

76.4 

12.4 

12.6 

15.0 

13.5 

7.8 

11.8 

13.1 

12.5 

13.1 

13.0 

10.4 

14.6 

11.2 

10.6 

32.3 

34.2 

30.0 

8.3 

8.0 

7.9 

3.9 

4.9 

5.0 

2.0 

2.0 

24.6 



Per 

cent. 

33.7 
10.7 

8.1 
23.6 
87.6 
87.4 
85.0 
.5 
92.2 
88.2 
86.9 
87.5 
86.9 
87.0 
89.6 
85.4 
.8 
.4 
67.7 
65.8 
70.0 
91.7 
92.0 
92.1 
96.1 
95.1 
95.0 
98.0 
98.0 
75.4 



Per 
cent. 

1.4 
0.4 
0.9 
1.4 
7.4 

23.1 
9.2 
8 

14 



6 
11 
11 

13.6 

11.9 

6.9 

3.3 

4.8 

8.8 

9.5 

8.4 

10.7 

10.3 

12.4 

11.3 

10.4 

9.8 



Per 

cent. 

1.4 
0.3 
0.7 
0.2 
0.4 
2.0 
3.8 
0.4 
7.1 
0.7 
0.8 
1.1 



1 
2 
1 
1 


0.6 
1.7 
1.4 
0.5 
9.9 
9.4 
4.4 
4.8 
13.7 
13.6 



Per 

cent. 

29.8 
9.7 
6.2 
20.5 
79.4 
59.2 
70.6 
77.4 
68.4 
78.1 
78.7 
74.9 
71.7 
70.0 
74.6 
76.1 
84.8 
83.4 
56.3 
53.3 
59.7 
68.7 
70.5 
74.2 
77.5 
69.6 
69.7 
97.8 
97.8 
73.1 



Per 
cent. 

1.1 

0.3 
0.3 
1.5 
0.4 



1 
4 
4 


7 
5 
8 
4 
4 

4 
6 
0.9 
1.6 
1.4 
2.4 
1.8 
1.1 
2.5 



Calo- 
ries. 

640 
200 
160 
415 
1,630 
1,615 
1,645 
1,620 
1,845 
1,635 
1,625 
1,645 
1,625 
1,640 
1,680 
1,605 
1,650 
1,665 
1,280 
1,225 
1,285 
1,895 
1,900 
1,795 
1,855 
2,035 
2,050 
1,820 
1,820 
1,360 



To establish the tolerance for sugars we may adopt the method 
of Von Noorden, which is somewhat as follows : At 7.30 a.m., before 
breakfast, the patient urinates and the urine is thrown out. Then 
he takes for breakfast a cup of black coffee with perhaps a raw egg 
stirred up in it. Then at ten o'clock he urinates and a sample of 
the urine is used for qualitative analysis. This analysis is imme- 
diately made, for upon it depends all further procedure. If it 
contains no sugar or diacetic acid (iron-chlorid test) then we pre- 
scribe a diet for the day that shall contain 100 grams of bread 
or 500 grams of milk. Thus, as soon as the result of the test is 
learned, black coffee, 1 to 2 eggs or meat, with 30 grams of bread. 



356 DISORDERS OF METABOLISM 

At noon— Bouillon with egg, 200 to 250 grams meat or fish, 
green vegetables, such as spinach, lettuce, cabbage, cauliflower, 
etc., prepared without flour, and 40 grams of bread, buttered ad 
libitum, and 20 to 30 grams of cheese. 

At 4 p.m. — Coffee or tea and an egg. 

At 6 p.m.— Meat or fish, with green vegetables, and 30 grams 
bread with butter. 

If milk be used instead of bread as the test food containing 
carbohydrates, it should be divided up among the various meals. 
No alcoholic drinks should be taken during these tests. 

The entire urine passed during the day, including that passed 
at ten o'clock and that passed next morning up to 8 a.m., should 
be carefully collected and measured. From this a sample should 
be taken for quantitative tests. 

If in this second examination sugar be found in the urine, the 
amount of bread for the succeeding day must be decreased to 50 
grams (or 200 c.c. milk) and the meals ordered as on the preced- 
ing day. 

If, on the other hand, no sugar is found, then the quantity of 
carbohydrate added to the diet may be increased, say by 20 
grams of bread, and so on, until sugar appear in the urine. This 
establishes the threshold of tolerance. 

Now, returning to the ten o'clock sample examined on the first 
day: If sugar be present, then the day's rations should include 
only 50 grams of white bread. If even this produce sugar, a 
smaller quantity should be tried the next day. 

If the first test show a positive iron-chlorid reaction, then the 
treatment for acidosis should be at once undertaken. This con- 
sists in giving 15 to 20 grams of sodium bicarbonate pro die, dis- 
tributed as is most convenient. 

The diet during the giving of the alkali may be the same as if 
the acidosis were not present, with this exception — that the amount 
of protein should be restricted. 

The general rule for the giving of carbohydrates is that the 
total daily amount should be below the threshold of tolerance. 
For instance, when the giving of 120 grams of protein produces 
sugar in the urine, the amount allowed should not exceed 80 
grams. 

In the bad cases, where there is little or no tolerance for sugar, 



DIABETES MELLITUS 357 

the diet should be selected from foods that contain at the most 
only a trace of carbohydrate. Thus Liithje recommends as an 
illustrative dietary: 

200 c.c. of cream. 

6 eggs. 
100 grams of butter. 

50 grams of cheese. 

50 grams of ham. 

50 grams of pork. 
100 grams of spinach. 
200 grams of veal. 

50 grams of green salad (lettuce) . 
200 grams of roast beef. 
500 c.c. of bouillon. 

And, in addition, tea, coffee, or mineral waters as beverage. This 
affords some 3,000 calories of heat energy. 

If even on such a restricted diet as the above sugar is still 
present in the urine, the amount of protein should be cut down. 
The limit to which the protein may be reduced is seventy to eighty 
grams a day. It is just such cases that show an intolerance for 
sugars derived from protein, but are able to take some carbo- 
hydrate sugar. 

In such severe cases it is well to introduce frequently vegetable 
days; that is, days on which only vegetables and fats are given. 
If, however, it is impracticable to use only vegetables and fats, 
two or three eggs may be introduced into the dietary. Thus we 
may give for such a " vegetable day " (Liithje) : 

8 a.m. — Asparagus with 50 grams of butter. 
10 a.m. — Spinach with 50 grams of butter. 
1 p.m. — Red cabbage (rotkraut) with 50 grams of butter. 
4 p.m. — Cabbage with 50 grams of butter. 
7 p.m. — Cauliflower with 50 grams of butter. 

These vegetables may be salted to suit the taste. Even sour wine 
may be added to the regularly permitted beverages (coffee, tea, 
mineral water). Opium (tincture) in small doses overcomes any 
tendency to diarrhea in using such a diet. 



358 



DISORDERS OF METABOLISM 



Another interruption to the monotony of the strict diet may 
be obtained by introducing in between the vegetable days, days on 
which oatmeal is practically the only food. 

Thus von Noorden gives 250 grams of oatmeal, distributed 
through the day at two-hour intervals, in the form of soup or 
porridge. The " soup " is made by having 50 grams of oatmeal 
boiled with 1 liter of water (or lightly salted bouillon) for forty 
minutes, then rubbed through a sieve. Salt and beef broth may be 
added to suit the taste. The porridge is made by adding 50 
grams of oatmeal to sufficient cold water, gently boiling for thirty 
to forty minutes, adding 30 to 50 grams of butter, and salting to 
suit the taste. The porridge is eaten with cream or cranberry 
sauce. The beverages are as on other days. Three or four such 
oatmeal days may be given in succession. 

As an illustration of this procedure we quote the following 
tabulation from the case history of a fifteen-year-old girl (who 
had been sick for three months when she came into treatment) 
from Liithje (" Handbuch d. Therapie," Vol. II, pages 76-77) : 







Absolute 


Ace- 
tone. 




o 


^s 




Date. 


Quantity 
of urine. 


quantity 
of sugar 


Diet. 


■c 

o 




Remarks. 






in urine. 


g- 






£ 




December 










250 ccm. milk 








1908 


900 








50 g. ham 








12-13 


incomplete 
1,500 


30.6 


33.5 


0.47 


50 g. white 

bread 
Strict diet 


250 




13-14 


22.5 


35.3 


1.85 


2,187 35.8 


3X5.0 g. Sod. 
















bicarb. 


14-15 


1,000 l 


17.5 


24.2 


1.81 


(< 


1,971 .... 


ii 


15-16 


1,500 


28.5 


32.7 


1.65 


«< 


2,584 35.8 


a 


16-17 


1,800 


30.6 


42.3 


2.52 


" 


3,038.... 


2X15 Gtt. Tct. 

opii+do. 
2X10 Gtt. Tct. 


17-18 


700 


3.5 


7.7 


0.68 


Vegetable day 


1,095 36.5 














| 


opii+do. 


18-19 


1,800 


22.5 


30.4 


2.17 


Strict diet 


2,675 36.9 


" 


19-20 


1,900 


30.4 


44.1 


3.04 


" 


3,067.... 


tt 


20-21 


900 


0.4 


7.8 


1.58 


Vegetable day 


1,512 .... 


5X10 Gtt. Tct. 
opii+do. 


21-22 


1,000 





1.0 


1.03 


a 


2,008 36.1 


" 


22-23 


1,500 





1.2 


0.79 


a 


2,352 37.0 


3X5.0 g. Sod. 


















bicarb. 


23-24 


1,500 








0.96 


CI 


2,747 


37.6 


n 


24-25 


1,700 








1.02 Strict diet 


2,873 


37.6 


" 


25-26 


2,000 


18.0 


25.0 


2.10| 2,354 


37.8 


a 


26-27 


18,00 


27.0 


34.2 


1.32 


n 


2,250 


37.2 


a 



1 Some urine lost. 



DIABETES MELLITUS 



359 



Date. 


Quantity 
of urine. 


Absolute 
quantity 
of sugar 


Ace- 
tone. 


Diet. 


"S 

jo 


XI 


Remarks. 






in urine. 


g- 




O 


£ 




December 


















1908 


















27-28 


1,300 


12.3 


17.9 


1.17 


Oatmeal day 


3,814 


36.5 


3X5.0 g. Sod. 
bicarb. 


28-29 


1,400 


24.5 


26.6 


0.29 


tt 


3,778 


36.9 


tt 


29-30 


1,400 


39.9 


? 


0.16 


tt 


4,012 


37.5 


tt 


30-31 


1,900 


7.6 


8.0 


0.11 


Strict diet 


1,568 


38.3 


tt 


31 to 


















1909 


















Jan. 1 


1,800 


29.7 


33.4 


0.64 


tt 


1,496 


38.0 


" 


1-2 


1,200 


7.8 


13.5 


0.96 


" 


1,736 


38.0 


n 


2-3 


1,600 


8.0 


13.1 


0.86 


ft 


1,540 


37.3 


n 


3-4 


1,700 


2.5 


? 


0.37 


tt 


1,540 


37.2 


" 


4-5 


1,800 


6.3 


8.4 


0.50 


tt 


1,580 


37.4 


a 


5-6 


1,700 


24.6 


28.2 


0.85 


tt 


1,434 


37.7 


tt 


6-7 


1,800 


14.4 


19.0 


0.82 


tt 


1,450 


38.0 


it 


7-8 


1,900 


7.6 


12.6 


0.07 


tt 


1,500 


37.8 


tt 


8-9 


1,550 


8.5 


13.4 


0.55 


tt 


1,513 


38.5 


" 


9-10 


2,100 


28.3 


31.3 


0.79 


tt 


1,913 


37.8 


tt 


10-11 


1,600 


17.6 


24.6 


0.52 


" 


2,180 


38.2 


it 


11-12 


1,600 


14.4 


17.2 


1.36 


tt 


2,019 


38.4 


tt 


12-13 


1,200 





3.0 


0.64 


Vegetable day 


1,888 


39.2 


" 


13-14 


1,800 





1.8 


1.09 


u 


2,112 


39.2 


" 


14-15 


2,100 








0.86 


u 


2,019 


38.4 


it 


15-16 


1,800 








0.46 


Strict diet 


1,824 


39.1 


it 


16-17 


1,700 








1.60 




2,275 


39.2 


3X15 Gtt. Tct. 
opii 


17-18 


9 a.m. 253 

10 A.M. 150 

from 10-8 

o'clock 


4.0 

2.8 
















2,000 


34.8 


32.0 


0.44 


Oatmeal day 


3,488 


39.8 


tt 


18-19 


2,100 


42.0 


45.2 


0.27 


" 


3,587 


40.6 


tt 


19-20 


2,800 
8-10 o'clock 


28.0 


30.4 


0.11 


tt 


3,619 


40.6 


tt 


20-21 


600 


2.4 


2.3 














1,600 






1.00 


Vegetable day 


2,073 


39.6 


tt 


21-22 


1,200 








0.13 


" 


2,167 


39.7 


ft 


22-23 


1,700 


10.2 


14.4 


0.69 


Strict diet 


1,946 


40.0 


tt 


23-24 


1,800 


14.4 


33.3 


1.27 


tt 


2,138 


39.5 


" 


24-25 


1,300 








0.10 


a 


2,175 


40.0 


ft 


25-26 


1,300 








1.19 


" 


1,570 


39.8 


ft 


26-27 


1,400 








1.06 


it 


1,570 


39.5 


3X15 Gtt. Tct 

opii 

15 g. Sod. 

bicarb. 


27-28 


1,400 








1.19 


tt 


1,570 


39.8 


tt 


28-29 


1,500 








? 


Vegetable day 


2,250 


40.1 


tt 


29-30 


1,600 








0.3 


" 


2,100 


40.3 


tt 


30-31 


1,700 








0.56 


' Oatmeal day 


3,580 


41.0 


tt 


31 to 


















Feb. 1 


2,100 


14.7 


26.0 


0.12 


tt 


3,400 


41.7 


tt 


1-2 


1,900 








0.07 




3,450 


42.2 


ft 


2-3 


2,600 











1 Vegetable day 


2,100 


41.4 


tt 



360 



DISORDERS OF METABOLISM 



Date. 


Quantity 
of urine. 


Absolute 
quantity 
of sugar 
in urine. 


Ace- 
tone 
g. 


Diet. 


m 

'u 
o 
"3 
O 


XI . 


Remarks. 


February 


















1909 


















3-4 


1,700 








0.22 


Vegetable day- 


2,160 


40.7 


3 X 15Gtt. Tct. 

opii 

15 g. Sod. 

bicarb. 


4-5 


2,200 








spur 


Strict diet 


1,465 40.5 


<< 


5-6 


1,900 








0.4 


" 


1,510 40.7 


« 












10 g. white 


















bread 








6-7 


1,900 








0.66 


Strict diet 

20 g white 

bread 


1,535 40.5 


«« 


8-9 


1,800 








0.9 


Strict diet 


1,535 40.4 














20 g. white 


















bread 








8-9 


1,600 








0.9 


Strict diet 


1,535 4] 














20 g. white 


















bread 









Transient glycosuria in young people should receive respectful 
attention and the diet carefully regulated for a year or two. If 
possible, its causation should be worked out and the patient's life 
arranged accordingly. 

The psychic or nervous form of glycosuria should be carefully 
differentiated. The cure is usually along psychotherapeutic lines, 
which, of course, include a regulation of the patient's activities 
and food to bring them within hygienic limits. These cases fur- 
nish the mass of the testimonials of quacks. 

When there is pancreatic insufficiency (steatorrhea, azotor- 
rhea), pancreatin should be given with calcium carbonate. The 
drugs should be given in larger doses than are usually found in 
the ready-made tablets of the pharmaceutical houses. For in- 
stance, forty-five grains each of pancreatin and calcium carbonate 
may be given three times a day, best in salol-covered capsules, two 
to three hours after food. 

Rarely the kidneys seem to be at fault and give a glycosuria 
when there is little or no sugar in the blood (hypoglycemia). 
These cases must be put on a very restricted diet, and special at- 
tention paid to the presence in the food of creatinin, phosphoric 
acid, and other renal irritants. 



RICKETS 361 

The complication of diabetes with tuberculosis is almost hope- 
less. In such cases the diet should be regulated to give the great- 
est nourishment with the least hyperglycemia. The egg and meat 
and fat (oils, butter) diet, with the interpolation of vegetable and 
oatmeal days, afford the best prospect of comfort to the patient. 

In cases of gout and obesity, both the glycosuria and the other 
troubles will be benefited by ordering as much open-air exercises 
as possible. For glycosuria is usually distinctly benefited by con- 
siderable muscular activity. 

RICKETS 

Rickets is a disease of metabolism or nutrition in which the 
growing bones show the greatest changes, hence measures to secure 
a greater absorption of the bone constituents are to be taken at 
the outset. The first of these seems to be the ingestion of larger 
quantities of sodium chlorid, the next seems to be the supplying 
of phosphorus; then follows the stimulant action of cool or cold 
sea-water baths, accompanied by careful rubbing and good hy- 
gienic living. 

The salt is, of course, supplied with the food by simply in- 
creasing its quantity therein. 

The phosphorus is supplied in a drug mixture of which the fol- 
lowing is an illustration : 

Phosphori 0.01 gr. T V ; 

Olei olivas 5.0 T!X 1 ; 

Pulv. acaciae 

Sacch. albi aa 10.0 gr. c ; 

Aquge 75.0 gjss. 

One half to one teaspoonful t. i. d. (Kassowitz). 

Or cod-liver oil may be combined with the phosphorus, e. g. : 

Phosphori 0.01 gms. 

Olei jecoris aselli 100.0 c.c. 

One half to one teaspoonful t. i. d. 

The salt baths may be made as strong as one half per cent of 
rock salt for older children. For the nurslings they must, of 
course, be much weaker. 



362 DISORDERS OF METABOLISM 

The patient should not remain long in the bath, but should be 
put into the tub with the water just cool enough to be stimulating. 
The water should be thoroughly splashed over and against the 
body and the child taken out and dried with gentle friction. 

Deformities are to be prevented by keeping the patient from 
using his body vigorously; hence he should be kept on a cot (in 
the open air most of the time) until the bones show firmness. 

Laryngospasm must be watched for and the child prevented 
from making its condition worse by excitement or struggle. The 
use of the bromids in nervous children, is therefore justified. At 
any rate, the attendants must be schooled to avoid doing anything 
to excite or frighten the child. 



CHAPTER IX 

INFECTIOUS DISEASES 

GENERAL CONSIDERATIONS 

The self-limited infectious diseases demand in some respects 
similar treatment without regard to the specific causal organism; 
for in a few we have some more or less causal therapy, but in the 
majority the treatment is largely expectant and symptomatic ; but 
in all these diseases isolation and precautions against spreading 
the disease are to be considered of primary importance. We shall 
here mention a few of the more important regulations applicable 
to the whole group. 

The sick room needs to be well lighted and ventilated. Its tem- 
perature needs to be maintained equably at 65° to 70° F. Ordinary 
ventilation is usually inadequate and the windows must be used 
to increase the interchange of air. 

The clothing and utensils and dishes used about the patient 
must be sterilized before they are put with the family supplies. 
Clothing may be soaked in hot crude carbolic-acid solution (four 
fluid ounces to the gallon), or, better, in a five-per-cent liq. cresolis 
comp., for thirty minutes before being put into the family wash 
(provided that the whole wash is thoroughly boiled; otherwise 
they must be boiled separately). Nonwashable clothing should 
be fumigated with formaldehyd in a closed room for twenty-four 
hours. Dishes and similar apparatus should be thrown into boil- 
ing water before being handled by the servants or members of the 
family. Even the attendant's clothing should be considered in- 
fectious and kept separate until disinfected. 

In all these diseases the care of the skin forms an important 
part of the treatment. When there are eruptions inunction with 
an antiseptic oil after the daily soap- and tepid-water bath is 
called for. When there are no eruptions cool rubs in addition 

363 



364 INFECTIOUS DISEASES 

to the cleansing baths are used to stimulate the skin and the 
vasomotor system. 

The intestinal canal must be kept free from fermenting putre- 
fying masses. In cases where the intestinal tract is the seat of 
the lesions only the very gentlest cathartics may be used, and the 
main dependence for emptying the bowel must be placed on ene- 
mata. In diseases other than those affecting the intestine it is 
rather immaterial which cathartic is used. In such cases the pa- 
tient's whims may be followed. The gentlest cathartic for infec- 
tious diseases is usually calomel, given in doses of one tenth to one 
fourth grain at hourly intervals until a grain or two has been 
given. For the initial catharsis Epsom salts (magnesium sulphate) 
in one-half- to one-ounce doses seems satisfactory. The more con- 
centrated the solution of these salts the more vigorous is the 
cathartic action. For convalescents the familiar Hinkle 's tablet * 
has proven very satisfactory. These may be given once, twice, 
or three times a day, as needed. Phenolphthalein does not seem 
to be satisfactory for this sort of work. 

Headache and backache are usually treated by giving the coal- 
tar analgesics, though in many fevers the diaphoretic Dover's 
powder, in five- to ten-grain doses, is preferred. 

Diarrhea in these disorders is treated usually with opium (ten 
to fifteen drops of the tincture), but where the intestine is con- 
gested the tannin albuminates (fifteen-grain doses) are preferable. 

In all these infectious diseases the care of the teeth and mouth 
should be looked after by the physician. He should see to it that 
the nurse brushes the teeth and cleanses the mouth with hydrogen 
peroxid or the alkaline antiseptic fluid (of the National Formu- 
lary) two or three times a day. 

In general the food should be liquid. Milk is the best base. 
Broths, bouillons, unfermented grape juice, eggnogs, etc., are all 
useful in keeping the peristalsis active and the mucosa of the in- 
testine free from debris. On the other hand, they are not liable 

1 ]$ Cascarin £ gr. 

Aloin \ 

Ext. belladonna leaves £ 

Oleoresin ginger tV 

Strychnin sulphate /o 

Podophyllum resin £ 



BACILLARY DYSENTERY 365 

to injure inflamed surfaces or set up indigestion. The first solid 
food for the convalescent may be scraped steak. If this goes well, 
oven-dried toast may be added; then it will be proper to give a 
mealy baked potato. Following this, cooked fruits and other solids 
may be added according to the appetite of the patient and the 
doctor's wishes. 

Because in fever there is already increased tissue consumption, 
patients should be kept quiet even if they do not appreciate the 
need of the bed rest. The recovery after the periods of full rest 
are more rapid and complete than when the patient has been al- 
lowed to move about. 

In the following paragraphs we name practically only those 
diseases for which there is some peculiar line of treatment to be 
given. The rest of the infectious disorders may be treated symp- 
tomatically according to the principles laid down in our discussion 
of symptomatic therapeutics. 

ACTINOMYCOSIS 

Actinomycosis requires, besides the regular symptomatic treat- 
ment, surgical treatment whenever possible. When it is not pos- 
sible to reach the growths, the iodid of potash should be given in 
solution in doses of fifteen to twenty grains three times a day. 
An illustrative prescription follows: 

I£ Potassii iodidi 22 grams ; 

Elixir, gentianag glycerinati (N. F.) . . . . 180 c.c. 
Sig. One dessertspoonful t. i. d. with or after food. 

ANTHRAX 

The treatment differs from that of other infective diseases in 
that wherever possible the malignant pustules should be burned 
out with the cautery or injected with carbolic acid or bichlorid 
of mercury. The rest of the treatment is purely symptomatic. 

BACILLARY DYSENTERY 

The first duty of the physician is to free the intestine of as 
much of the putrefying and fermenting masses as possible. This 



366 INFECTIOUS DISEASES 

is best accomplished by giving magnesium sulphate in ounce doses 
until the stools become less offensive. 

The next step is to use some drug that will inhibit the bac- 
teria still remaining in the colon. For this ipecac seems the most 
successful. Forty to sixty grains of this drug in pills covered 
with salol are administered daily on an empty stomach (see Amebic 
Dysentery). If necessary, laudanum or morphin is given before- 
hand. The dose is gradually decreased on the succeeding days. 

Where it may be well done, high colonic injections of quinin 
bisulphate (1:500 to 1:1,000) should be used daily. If the anus 
and rectum be tender a preliminary anesthetizing of the rectum 
should be done with quinin or cocain or belladonna. The tube 
should be inserted with the water flowing and slowly pushed up 
until it is past the sigmoid flexure. Nitrate of silver may also 
be used for the irrigating solution in the strength of one or two 
grains to the ounce. 

The diet must be nonirritating and of the kind to be absorbed 
in the upper intestine, thus milk and eggs should be its chief con- 
stituents. If curds appear the food should be peptonized. Shiga's 
serum may be used, but its results show that it is not at all specific, 
hence we must for the time being depend upon the above line of 
treatment. 

CHICKEN POX 

Chicken pox requires no special treatment. The principles 
governing the treatment of infectious diseases are sufficient to 
guide the student here. The mouth and the itching need looking 
after according to the principles used in all infections, that is, 
the former should be thoroughly cleansed twice or thrice daily 
with an alkaline antiseptic or with hydrogen peroxid, and the 
skin kept comfortable with a mentholated oil. 



CHOLERA 

For this disease we have both a serum (Gaffky, Kitasato) and 
a vaccine (Haffkine's). We immunize with the latter, we combat 
the established disease with the former. The success of both pro- 
cedures has been called into question, but doubtless continued 



CHOLERA 367 

experimentation will perfect both products until we can see as 
good results here as with diphtheria. In the present state of 
affairs, we should in case of need use the vaccine or serum if 
it be available, but place our reliance on the symptomatic pro- 
cedures. 

The disease is hardly more infective than typhoid, hence under 
careful supervision it ought not to spread rapidly. The precau- 
tions to be observed to prevent the spread of the disease are enu- 
merated thus by Tyson: 

(1) The vomited matter and the discharges from the bowels 
are to be gathered in carbolic solution (1 to 20) or chlorinated 
lime (1 to 10), some of which should be in the vessels before it is 
used; after use, more should be added. The matter thus collected 
should be gently stirred and allowed to remain twenty minutes 
before being poured into the water-closet hopper. When the ex- 
creta can be thrown into a pit, or even, as may be done in the 
country, on a manure pile, milk of lime, or what is the same thing, 
ordinary whitewash, is a very efficient and cheap medium with 
which to disinfect them. 

(2) After vomiting, the mouth of the patient should be rinsed 
with a solution of hydronaphthol (1 to 5,000), care being taken 
that none is swallowed. After each evacuation from the bowels, 
the buttocks, thighs, and anus should be washed with soap and 
water. 

(3) All body and bed linen soiled with the discharges should 
be immediately moistened with carbolic solution (1 to 60) and 
removed in a covered vessel from the apartment, placed in a wash- 
boiler, and boiled for half an hour in a one-per-cent solution of 
washing soda. 

(4) Napkins, towels, and table linen should be placed in a 
similar vessel or canvas bag for removal and similarly boiled. 

(5) All dishes, knives, forks, spoons, etc., used by the patient 
should be boiled after each meal in a one-per-cent solution of 
soda. 

(6) The remains of meals should be thrown into a vessel con- 
taining milk of lime or whitewash, and removed at the end of 
the day. 

(7) Door knobs are liable to be soiled by the hands of one car- 
rying out excreta, and should be carefully washed and cleansed and 

25 



368 INFECTIOUS DISEASES 

sterilized lest they, in turn, communicate the infectious material 
to another person handling them. 

(8) In case of death, the body, without being washed, should 
be wrapped in sheets wet in a solution of bichlorid of mercury 
(1 to 1,000) and allowed to remain until removed for prompt 
burial. 

Special Directions to Nurses. — (1) Nurses of cholera patients 
should not hold any direct communication with others during at- 
tendance on such cases. 

(2) They should under no circumstances take their meals in 
the same apartment with the patient, and before leaving the room 
the hands should be cleansed with soap and bichlorid solution 
and such portion of the dress as is liable to be soiled should be 
changed. The hands should be again rinsed in bichlorid solution 
(1 to 100) after leaving the patient's room. A very convenient 
plan is to wear a slip or " overall " with a hood to cover the hair, 
which can be easily thrown aside before leaving the room. A 
canvas slipper or overshoe, readily removed, should always be 
worn in the sick room. 

(3) The food of the nurse should be wholesome and plain, 
freshly cooked, and served hot. No uncooked vegetables should 
be eaten. Milk should be boiled and, if desired, cooled before 
using. Cold drinks should be taken moderately, if at all. Coffee 
and tea may be taken hot. 

(4) The teeth should be cleansed after each meal, as the mouth 
affords peculiarly favorable nidus for decomposing matters and 
for the multiplication of pathogenic fungi. A daily bath in warm 
water with the use of soap should be taken by each nurse. 

(5) Care should be observed to keep the body from being 
chilled by draughts or other cool exposures, and to this end woolen 
underclothing should be worn. 

(6) Courage and cheerfulness are amply justified, because it 
is really almost impossible to take cholera if the above precau- 
tions are carried out. 

The pains and beginning diarrhea are treated by subcutaneous 
injections or morphin in full doses. 

The collapse is treated by giving hot drinks and applying ex- 
ternal heat. A patient may be put into a tub of hot water (110° to 
120° F.) and left fifteen minutes to overcome the severe lowering 



YELLOW FEVER 369 

of the body temperature. If this does not succeed, subcutaneous 
and intravenous injections of sterile salt solution at 107° F. should 
be resorted to. 

The vomiting should be treated by gastric lavage with hot 
water, by the giving of cocain (one fourth grain) or other gastric 
sedative. 

The colitis requires colonic irrigation; one to two quarts of a 
one-per-cent solution of tannic acid will precipitate the vibrios 
as well as constrict the mucous membrane. 

YELLOW FEVER 

We are not yet in a position to give more than simple symp- 
tomatic treatment for this disease. 

Our first duty is to remove the patient to an uninfected, isolated 
room. Then both the bed and the room should be thoroughly 
screened, for to prevent the spread of the disease we have chiefly 
to guard against the presence and bites of the stegomyia mos- 
quito, hence we cannot be too careful with our fumigation and 
screening. 

We must rely chiefly upon good nursing to bring the patient 
through the attack. This will be shown chiefly in the giving of 
baths, and rubs to promote sweating and the elimination through 
the skin of the toxins of the disease. 

The pains and backache are helped by acetphenetidin and 
quinin bisulphate, each in five-grain doses, repeated as needed 
(e. g., every three or four hours). 

The vomiting may be helped by swallowing small pieces of ice, 
by acidulated drinks, by belladonna, or by cocain. 

The hemorrhages are treated by ergotoxin or adrenalin subcu- 
taneously. 

The heart is kept even by camphor, caffein, or digitalis, accord- 
ing to whether it is a vasomotor or myocardial weakness. 

Nourishment may be given by the rectum, and should always 
be so given when there is gastric irritation. 

In short, we follow the principles laid down for symptomatic 
treatment throughout. 

The patient should be allowed to drink freely. 

In a comatose stage one should resort to hot baths, hot packs, 



370 INFECTIOUS DISEASES 

mustard baths, etc., to rouse the skin circulation. At the same 
time hot drinks should be given and the administration of normal 
salt solution by hypodermoclysis pushed to the limit. 

If the patient recovers he should be carefully watched to pre- 
vent dietetic errors. He should be given bitter tonics and light 
cathartics to stimulate the digestive tract. Massage and salt baths 
will also assist him to regain his strength. 

ERYSIPELAS 

Erysipelas is usually self-limited, but the resistance of some 
patients is so low that there is little or no systemic immunity de- 
veloped, and the disease continues for weeks, spreading from one 
part of the body to another, hence the expectant plan of treatment 
cannot be adopted in all cases. 

The aggressive treatment is by means of the antistreptococcic 
serum. The more polyvalent the serum the greater the likelihood 
of success. This should be introduced in doses of 20 to 30 c.c. at 
eight- to twelve-hour intervals until the spread of the disease is 
checked. When possible, the injections should be made into the 
inflamed area. 

The symptomatic treatment consists in relieving the local dis- 
comfort and in stimulating the vital functions. The first is ac- 
complished by applying a thick paste over the inflamed surface. 
Unna's jelly is excellent, but good results may be obtained by 
using vaselin and ichthyol in equal parts. The second is obtained 
by keeping the bowels active and the bodily functions well stimu- 
lated. The following prescription may serve to illustrate the 
treatment : 

•^ Tct. nucis vomica? 5.0 c.c. 

Hexamethylenaminee 4.0 grams. 

Fl. ext. cascarse sag 1.0 c.c. 

Elixiris aromatici 40.0 ' ' 

One teaspoonful t. i. d. 

Collapse must be watched for and guarded against. In laryn- 
geal involvement one must be ready to intubate or perform 
tracheotomy. 



HYDROPHOBIA 371 

Erysipelas is extremely infectious and must be thoroughly iso- 
lated. It is particularly dangerous for a doctor to. treat erysipelas 
and at the same time try to do obstetric service. Likewise the 
nurse must thoroughly disinfect herself and her clothing before 
she goes to another case. 

GLANDERS 

Whenever possible, the cleaning out of the local infection 
should be practised; otherwise the treatment is symptomatic. 

HYDROPHOBIA 

Rabies is an acute, specific, rapidly fatal malady communicated to 
man from some lower animal. It is always an inoculation disease, that 
is, communicated directly through a wound, usually made by the teeth, 
the infective matter being the saliva, which contains the virus. 

The dog is, by far, the most frequent source of rabies not only for 
man, but for all other animals. The bites of other rabid animals, includ- 
ing cats, wolves, foxes, horses, cattle, etc., are, however, quite as dan- 
gerous as that of the dog. Rabies may also be transmitted by deposits 
of saliva, containing the virus, on abraded surfaces, as by licking; or 
through wounds received in making autopsies on persons or animals 
who have succumbed to the disease. The saliva of the dog has been 
shown to be virulent twenty-four to forty-eight hours before the animal 
exhibits any symptoms of illness. Therefore, if a person is bitten by an 
animal which develops rabies later, it is advisable to take the treatment 
as a protective measure. 

The bite of any suspicious animal should receive prompt attention. 
The invariable rule must be to cauterize as soon as possible, and in the 
meantime do everything possible to get the virus out of the wound and 
prevent absorption. Open the wound freely and bathe abundantly with 
tepid water, if convenient. If the wound is on the limb, a ligature may 
be applied above the site. Fuming nitric acid is the best cauterizing 
agent for this purpose. If nitric acid is not available, the actual cautery, 
carbolic acid, or lunar caustic may be used, though the two latter will 
coagulate the albumen of the tissues and therefore will not deeply pene- 
trate. The importance of early and thorough cauterization cannot be 
overstated. This should never be neglected, since it retards the develop- 
ment of the disease, and thus renders the Pasteur treatment more cer- 
tain of effect. It must be borne in mind that the Pasteur treatment is a 



372 INFECTIOUS DISEASES 

preventive, or immunizing, treatment, and that there is no known cure 
for rabies. Therefore it is very important that the treatment be begun 
as. soon as possible after the infliction of the bite or wound. 

When a person is bitten by an animal suspected of having rabies, the 
animal should not be killed, but be kept securely confined. If the ani- 
mal has rabies, it will die within a few days showing symptoms of the 
disease. On the other hand, if the animal has already been killed, the 
head, with the neck attached, should be sent to some laboratory for ex- 
amination. Most state and municipal laboratories have facilities for 
this work. 

Antirabic virus or vaccine, as used in the Pasteur treatment for the 
prevention of rabies or hydrophobia in exposed persons, consists of the 
spinal-cord material of rabbits which have died from rabies (or have 
been killed just before its termination), which has been induced by the 
subdural inoculation of the fixed virus of the disease. This fixed virus 
is obtained by the serial passage of the rabies as met in nature (as, 
for instance, in mad dogs), through many successive rabbits. By this 
procedure it acquires finally a virulence which for any given strain of 
virus is fixed, and the incubation period of the disease caused by it in 
animals is uniform. At the same time its pathogenic properties have 
been modified so that it is less capable of causing rabies if inoculated 
subcutaneously. 

In Pasteur's method of treatment the spinal cord of the rabbit is 
dried for a time over caustic potash, at a temperature of 23° C, the 
result of this treatment being that the cord gradually loses its viru- 
lence, this so-called attenuation being probably a numerical decrease 
of infective units rather than a qualitative change. In inoculating 
persons who have been bitten by rabid animals those cords are admin- 
istered first which have been dried so long that their infectious proper- 
ties have become lost, and then on successive days cord is administered 
which has been dried for a shorter and shorter time, and which is con- 
sequently of increasing potency. 

The virus or vaccine consists then of the spinal-cord material of the 
rabbit, plus the microorganism of rabies and its products, artificially 
modified as to its pathogenic properties. 

It is administered subcutaneously, after being emulsified by rub- 
bing up in a mortar with a bland fluid, such as physiologic salt solution 
or bouillon. The anterior abdominal wall is the most suitable site for 
inoculations. The treatment lasts from two to three weeks, according 
to the formula adopted by the institution providing the treatment, and 
is usually modified according to the severity and site of the injury. 
Injections are given daily. — Stimson (Journal of the American Medical 
Association, January 22, 1910). 



INFLUENZA 373 

It should be remembered that this is a vaccination in which the 
patient develops his own antibodies, hence it is useless after the 
hydrophobia has developed. The treatment in such cases is purely 
symptomatic. 

INFLUENZA 

Influenza has no specific treatment. Its course is ordinarily 
so short that our treatment needs to be directed more toward sus- 
taining the patient's strength than toward aborting the disease. 
This line of treatment demands that our patients take time to be 
sick. Even if they feel that they can drag themselves around, they 
should not be allowed to do so, because influenza, though of short 
duration, is a powerful depressant and renders its victim sus- 
ceptible to prostration from work, worry, and disease, which ordi- 
narily would have little or no effect upon him. Patients suffering 
from influenza should therefore be put to bed for two days at 
least, and as long as the temperature remains above normal. 

The chief symptom is the pain — the backache, headache, leg- 
ache — and this seems best relieved by central depressants. Of 
these the coal-tar analgesics are most effective. We may there- 
fore give antipyrin, acetphenetidin, or acetanilid in five-grain 
doses every two to four hours, according to the patient's reaction. 
With the active drug should be combined sodium bicarbonate to 
render it less toxic. Yeo recommends that quinin be added to this 
analgesic treatment. When this is done, probably the most ef- 
fective method of administration is to combine the antipyrin and 
quinin in an effervescent mixture, thus: 

IJ Antipyrin 10 grams. 

Quinin bisulph 15 " 

Sacch. sod. bicarb. (N. F.) 235 " 

Sacch. tartaric acid (N. F.) 115 

Sacch. citric acid (N. F.) 115 " 

M. f . mist, effervescens. Sig. : One heaping teaspoonful in a 
glass of water every three hours. 

Hot baths and massage also assist in rendering the patient 
more comfortable. 

The gastrointestinal symptoms demand cathartics and anti- 



374 INFECTIOUS DISEASES 

septics to prevent or overcome the stagnation and putrefaction in 
that tract. Thus a capsule or powder made up of the following 
would give great relief: 

I£ Acetphenetidini 0.3 grams. 

Hydrargyri chloridi mitis 0.05 " 

Phenyl salicylatis 0.3 

One of these might be given an adult every four hours, with 
plenty of water. 

The respiratory form is the most dangerous; therefore, while 
we relieve the ordinary symptoms of discomfort, we should watch 
closely the heart and general vitality. We treat the bronchitis 
with vaporized medication, we apply packs for the pneumonia, 
we use the depressant drugs — quinin, acetanilid, etc. — more cau- 
tiously than in the other forms of influenza, and do not hesitate to 
use digitalis and strychnin at the first sign of cardiac or respir- 
atory weakness. 

It is important to diagnose the localized forms of influenza 
early and try to eliminate the toxins from the system. The use 
of sterile salt solution subcutaneously and by rectum, the use of 
hot packs, and, finally, the use of alcoholic stimulants should here 
be considered as in septicemia. The alcoholic beverages would be 
justified here, if anywhere, because the course of disease is so short 
that their stimulant effect would not have yielded to the depress- 
ant ones before the disease has run its course. 

Since the presence of the bacillus influenza? causes the rapid 
development of a mixed infection, especially in the upper air pas- 
sages, it is wise from the very onset of the disease to prescribe in- 
halations of steam charged with oil of eucalyptus in an effort to 
cleanse the passages as thoroughly as possible. Such inhalations 
should be given for ten minutes three or four times a day, either 
with a regular vaporizer or with a bowl of boiling water (e. g., 
chafing dish) containing a film of the oil. A towel or sheet over 
the head will enable the patient to secure a greater amount of the 
vapor. 

In the cerebrospinal type cold must be applied to the head, 
which may be shaved in order to secure greater effect. Hexa- 
methylenamin and cathartics should be given to prevent the 
greater development of the bacilli, thus: 



MEASLES 375 

T$> Pulveris hexamethylenaminae effervescentis (N. F.) 100.0 
Sig. : One heaped teaspoonful in water every four hours. 

As soon as the convalescence sets in, it is wise to prescribe 
tonics and carefully regulate the diet and exercise in order to 
avoid the long, dragging exhaustion usually following influenza. 
Thus, the tincture of nux vomica, with dilute hydrochloric acid, 
in a vehicle of essence of pepsin, given with the food will assist 
greatly in affording the needed stimulation. 



MALARIA 

The treatment of malaria is, fortunately, specific and causal. 
Its basis rests on the flooding of the blood with quinin at the time 
when the corpuscles rupture and the plasmodia swim freely in the 
blood current; hence when there are definite cycles we prescribe a 
half gram (7j grains) of quinin bisulphate eight hours before the 
expected outbreak of fever and the same quantity four hours 
later (i.e., four hours before the fever). In other cases we give 
smaller quantities of the quinin at short intervals throughout the 
day and thus keep the blood saturated with the quinin. For in- 
stance, three grains may be given every two hours very sat- 
isfactorily. 

Aside from the specific treatment we may treat the symptoms 
as they arise. In particular, we need to treat the constipation, 
for in nearly every case there is a sluggishness of the bowels that 
calls for frequent catharsis, hence calomel is frequently given with 
the initial doses of quinin. 

Since the quinin destroys only the free swimming forms of the 
Plasmodia, it is necessary to continue the exhibition of drug for 
some days even after the fever subsides in order to destroy iso- 
lated belated parasites as they break out from their corpuscles. 
The dosage for this purpose need not be as great as that for com- 
bating the fever. 

MEASLES 

Measles requires that particular attention be given to the re- 
spiratory tract. In the beginning of the disorder the infectious 



376 INFECTIOUS DISEASES 

nasal discharge needs to be carefully secured and disinfected. The 
respiratory passages should be treated by the inhalation of steam 
containing the oil of eucalyptus. Should bronchitis develop it is 
treated as in the ordinary attacks of that disease. 

Should the eyes be unable to bear the bright light of the ordi- 
nary sick room, red curtains should be used, otherwise the prin- 
ciples governing the sick room in infectious diseases hold good. 

The conjunctivitis may even require a drop or two of adrenalin 
chlorid daily. This drug may also be needed for the rhinitis. 
(Apply by pushing a pledget of cotton saturated with it into the 
nostril and letting it remain five minutes.) The mouth must have 
its daily cleansing with hydrogen peroxid. The bowels must be 
kept loose with small doses of calomel, assisted by daily enemata. 
Vigorous catharsis should not be employed during the eruptive 
stage, lest the irritation of the mucosa, thereby set up, cause ulcers 
from the mucous eruptions. The skin is kept soft and smooth 
with oil rubs. The daily cleansing baths are given as in other 
diseases. One need not fear to " drive in " the disease. Com- 
plications and symptoms are treated as they arise. 



GERMAN MEASLES 

German measles requires only an initial clearing of the intes- 
tinal tract, and then a quiet, secluded life until all symptoms are 
past. The treatment is entirely symptomatic. 



THE PLAGUE 

For the plague we have both a vaccine (Haffkine) and a serum 
(Lustig and Yersin-Roux) that are much more effective than the 
corresponding products for cholera; hence in a time of epidemia, 
or on going into a plague district, physicians should provide them- 
selves with these two products. In case of the serum it is im- 
portant that it should be used at the earliest possible moment j 
hence as soon as a well-grounded suspicion is present that the 
patient has the plague we should inject 60 to 80 c.c. of the serum, 
half intravenously and half subcutaneously. Then we repeat the 
injections every twelve to twenty-four hours during the next five 



SCARLET FEVER 377 

days. The above is the dose for the adult. Even 400 c.c. have 
been injected intravenously without harm. 

Otherwise we endeavor to make the patients as comfortable as 
we can. Alcoholic stimulants should be used. In other respects 
there is hardly any restriction on the symptomatic treatment. 



SCARLET FEVER 

Here also the treatment is expectant and symptomatic. The 
one precaution to be taken in all cases is the avoidance of every- 
thing that might excite a nephritis. This includes the avoidance 
of the chilling of the body, of the ingestion of renal irritants in 
either the food or the medicine, and of severe exercise or move- 
ment that might cause renal congestion or fatigue. 

The room needs to be light and airy and to be kept at an even 
temperature (65° to 70° P.). Antiseptic precautions need to be 
taken as in other infectious diseases. In particular, it is important 
that all objects, books, and playthings handled by the patient be 
either burned or disinfected under compressed steam. 

Even after the fever has subsided the patient should be kept 
in bed. Ordinarily, it is wise to prescribe bed rest for two or 
three weeks. 

The food should be bland and " chlorid poor " (see Nephritis), 
hence milk is the best diet. Buttermilk or lactic-acid " butter- 
milk " and fruit juices may be used when the patients cannot or 
will not take sweet milk. 

The skin should be kept moist with oil rubs. Thymol, methyl 
salicylate, or menthol should be added to olive oil or vaselin to 
render it the more soothing. Before the daily oil rub, a cleansing 
bath should be given with warm water and a mild soap (such as 
Castile or Ivory). 

The patient should be encouraged to drink water freely. 
Lemon juice, citric acid, or hydrochloric acid may be added to 
render the drinking easier. 

The mouth should be kept clean by daily cleansing with peroxid 
of hydrogen. In addition, the fauces should be sprayed (with an 
atomizer) with the liquor antisepticus alkalimus (N. P.) in twen- 
ty-five-per-cent dilution. Should the throat become sore and cov- 



378 INFECTIOUS DISEASES 

ered with membrane or ulcerated, these spots should be carefully 
touched with the solution of the chlorid of iron. 

The bowels should be kept open with small doses of calomel; 
e. g., one tenth of a grain every hour until ten are taken each day. 

Inflamed lymph glands should be rubbed with guaiacol (fifty 
per cent in oil) or iodin (ten per cent in saponated petrolatum). 

Nephritis should be treated as described under that head. Car- 
diac weakness may call for the ice bag and cardiac stimulants. 

Otitis media requires usually the services of a specialist. If 
one is not available, then the following principles should be fol- 
lowed: The pain is best relieved by the application of heat, 1 al- 
though it may be necessary to give morphin at first. If the drum 
is tense and bulging it should be lanced. If a purulent discharge 
follows the paracentesis the ear should be washed out daily with 
a weak antiseptic solution, permitting a quart or two to flow 
through the external canal at each treatment. This is best done 
with a fountain syringe. After perforation, either spontaneously 
or by incision, the ear should be insufflated from the nose with a 
Politzer bag at least once a day, to drive the pus outward from 
the middle ear and also to stimulate the circulation. One may 
assist in the process of healing by using a large Bier's cup over 
the ear to induce hyperemia. A daily treatment of forty -five min- 
utes should be given. The cup should be large enough to fit over 
the ear. It fits better to the skin if its edges are covered with 
vaselin. 

SEPTICEMIA 

Septicemia may be treated along two lines: (1) Active attack 
on the infecting organism, as, for example, the infective organism 
may be isolated and the appropriate serum used, and (2) the 
body should be stimulated to withstand the depression due to the 
toxins. 

First of all, if collections of pus can be found they should be 
opened and drained. Only when such an opening would be cer- 

1 Yeo advises the following procedure for relieving the pain : Heat a wineglass 
by pouring hot water into it, and then pour 10-20 drops of chloroform upon a 
small piece of cotton wool in the bottom of the glass and hold the glass close 
over the affected ear. 



SEPTICEMIA 379 

tainly fatal should we abstain from giving the patient the benefit 
of the relief from the abscess. 

Serum Treatment. — The usual cause of septicemia is one or an- 
other strain of streptococcus, hence, even where we cannot isolate 
the organism causing the infection, but feel sure that it is a strep- 
tococcus, we may administer one of the standard polyvalent anti- 
streptococcic serums. These are made from the blood of horses 
rendered immune to several strains of human streptococci. Of 
the Parke, Davis & Co. serum, for example, we are told to inject 
for a light case 10 c.c. every eight to ten hours. In severer cases 
20 to 40 c.c. every six to eight hours are injected. If the effect 
is what it should be the patient's temperature falls within twenty- 
four hours. The injection should be made where the skin is loose 
and there is abundant loose areolar tissue to take up the fluid; 
e. g., back, thighs, and abdomen. 

Antiseptics. — If we cannot use a serum we may try the effects of 
hexamethylenamin in doses of five grains every four hours, in es- 
sence of pepsin as a vehicle. We cannot expect great things from 
this drug, but it does render some of the body fluids less hospitable 
to the streptococci. 

Or again, we may follow Porchheimer and use the colloidal 
silver of Crede. This is used as an ointment (unguentum Crede) 
for inunction or as a fluid (collargolum) for intravenous injection. 
The former must be used in large doses; for instance, 4 grams 
twice a day for infants, or 15 grams morning and evening for chil- 
dren. In adults Forchheimer believes that he gets better results 
by injecting 0.3 to 0.5 gram suspended in sufficient water into the 
rectum from once to thrice daily. In using the ointment care 
should be taken not to wash it off the skin. 

Supportive Treatment. — Now, as for sustaining the patient's 
strength, we may try first to remove as much of the toxin from the 
system as possible by venesection and replacing the blood removed 
with sterile salt solution, or we may inject the salt directly into 
the vein without removing the blood. This, of course, increases the 
blood pressure and the diuresis, but may put too great a load 
on the heart; or we may inject 250 c.c. directly under the skin 
(hypodermoclysis) ; or, finally, we may inject slowly two or 
more liters into the rectum. All these methods seem to dilute 
the toxins and stimulate the heart. We may add to these elim- 



380 INFECTIOUS DISEASES 

inative effects by using the hot-air bath or hot pack to promote 
diaphoresis. 

Systemic stimulants are required, and it is usual to give every- 
thing from whisky to strychnin. I believe it better, however, to 
use stimulants more selectively, reserving alcohol for emergencies 
and using nux vomica, caffein, and camphor, as the changing con- 
ditions indicate. Thus the nux vomica stimulates the gastroin- 
testinal tract and helps remove the coating from the tongue. Caf- 
fein is a rapid vasomotor tonic and stimulates the brain. The 
camphor is more sedative and also slower. 

After the fever falls the patient is utterly prostrate and must 
be kept quiet and under careful tonic treatment for weeks. In this 
treatment the great needs are bed rest ( alternated with out-of-door 
exercise), extra food (e.g., like that given in consumption), good 
air, and carefully selected tonic medication (e. g., mercury, ar- 
senic, and iron). 

SMALLPOX 

Ordinarily the diagnosis is not made during the initial stage 
preceding the eruption, and the symptoms, pointing as they do to 
influenza, usually are given that line of treatment. When, how- 
ever, the diagnosis is made, the treatment, although still symp- 
tomatic, should be less depressant. Thus, for instance, instead of 
giving acetphenetidin for the backache and malaise, Dover's pow- 
ders and hot baths (or packs) would be chosen. Of Dover's 
powders one gives 1 to 5 grains to a child, 10 to 12 grains to an 
adult. To assist in the diaphoresis the following alkaline draught 
(Yeo) might be ordered: 

5 Ammonii carbonatis gr. v ; 

Potassii bicarbonatis gr. xv ; 

Liquoris ammonii acetatis 3i j ; 

Syrupi aurantii 3j ; 

Aquae ad §jss. 

Take with fifteen grains of citric acid (to render it effervescent) 
every four hours. Children one half this dose. 

The patient should be allowed to drink freely of acidulated 
fluids — lemonade, egg lemonade, phosphoric-acid lemonade, etc. 



SMALLPOX 381 

The diet should be light — milk, buttermilk, broths, etc., at short 
intervals. 

Of course, as soon as the diagnosis is made the patient is iso- 
lated. For the sick room a large, well-lighted, well-heated, well- 
ventilated room on the second or third floor should be chosen. This 
should be freed of all unnecessary bric-a-brac and furniture. A 
sheet saturated with carbolic acid or formalin should be hung over 
the doorway and only the one (immune) attendant allowed within 
the room. The disagreeable odor from the patient may be combated 
by burning joss sticks or by saturating sponges or blotting paper 
with eucalyptus or other essential oil. The nurse must not go out- 
side the isolation limits or mingle with the family without chang- 
ing her clothing and taking an antiseptic bath. All excretions of 
the patient should be immediately burned or disinfected with for- 
malin. Thus the sputum cup should have a layer of formaldehyd 
solution, say one fourth inch thick, in the bottom. Flies and other 
insects must be screened out. 

Before the convalescent patient rejoins the family he must be 
thoroughly cleaned up with antiseptic washes. Even the hair 
must be washed with corrosive sublimate or carbolic-acid solution. 

In case of death the body must be wrapped in a sheet wrung 
out in formaldehyd solution. 

The room, at the termination of the disease, should be fumi- 
gated with formaldehyd. Thus for a room of 2,000 cubic feet one 
should take two pounds of potassium permanganate and two quarts 
of forty-per-cent formaldehyd solution. The permanganate is put 
in a three-gallon pail, and this set in a large dish pan containing 
water. After all is ready — the closet doors open, the bedcovers 
loosened up, and the windows and doors tightly shut — the solution 
is poured over the permanganate and the operator beats a hasty 
retreat and seals up the door. The room should be left closed for 
twenty-four hours at least. 

The fever may be lessened by bathing the patient in cool water, 
as we do for typhoid fever. The patient's reaction must, of course, 
be watched and the baths discontinued if they give too great a 
shock. When the eruption is fully out the fever is less and the 
greatest discomfort is from the itching. Antiseptic oils should 
then be used to keep the skin soft and comfortable. Such an oil 
might be made up as follows: 



382 INFECTIOUS DISEASES 

]J Thymol 5 grams. 

Guaiaeol 10 e.c. 

Olive oil 85 " 

Pitting is hard to prevent. The best results have been obtained 
by using red light (all the apertures in the room covered with red 
cloth or paint) or the ultra-violet ray. Both of these procedures 
are difficult to obtain outside of a hospital specially equipped for 
the purpose, hence in ordinary practice we must content ourselves 
with the application of antiseptic oils. The best results from such 
appliances have been obtained with ichthyol ointment (ichthyol, 
10; lanolin, 40; benzoinated lard, 50). The pain of the eruptions 
is best relieved by hot fomentations. 

The diet must be liquid and bland, but as nutritious as can be 
devised. Thus milk, eggnogs, and meat soups must stand fore- 
most in the dietary. 

The bowels must be kept loose. Thus a general prescription 
might be made as follows: 

^ Tct. nucis vomicae 10.0 c.c. 

PI. ext. cascarae sag 2.0 " 

Acidi hydrochlor. dil 20.0 " 

Glycerini 

Aquae aa 40.0 " 

One teaspoonful t. i. d. after food. 

The causal treatment is still applicable only in the incubation 
period — vaccination; hence after the onset of the disease we can 
use only the so-called expectant plan of treatment, and treat the 
symptoms and emergencies as they arise; but if an unvaccinated 
person be exposed, he may with profit be vaccinated even after 
two or three days. 

The technic of vaccination is somewhat as follows: We use for 
vaccination the skin over the deltoid muscle of the arm less used 
by the patient. We cleanse the area with soap and water, alcohol, 
and ether; then we make three crosses with a sharp knife, making 
the incision just deep enough for the blood to show, but not deep 
enough for it to flow; then we blow into each cross a little of the 
glycerinated virus from a capillary tube. We use a rubber bulb, 



SMALLPOX 



383 



not our lips, to blow with, and then rub this into the incision with 
our knife blade. The virus is allowed to dry in the air. When 
dry the incision is covered with sterile gauze or cotton held in 
place with adhesive strips. This dressing should not be disturbed 
for three days at least. It is usually better not to disturb it for 





Fig. 58. — The Two Methods of Vaccination. 



six days unless some emergency demand it, because each dressing 
affords a new opportunity for infection. Of course the operator 
should have his sleeves rolled to the elbows and his hands and fore- 
arms clean. Equally, of course, the instruments and towels should 
be sterile. 

Many prefer to use virus dried on an ivory point and scarify 
two or three places of the size of a dime, about one inch apart. 
The ivory point is sufficiently sharp to scarify with, thus obviat- 
ing the need of a knife. The virus is rubbed in and dried. A 
sterile bandage is applied and left in place from three to six 
days. 

It is important that the virus be fresh and active, and equally 
important that it be free from pathogenic organisms, hence we 
should be careful to secure only the best virus and that from the 
best manufacturers. 

Infants under six months should not be vaccinated. Skin dis- 
eases also act as a contraindication. Otherwise everyone should 
26 



384 INFECTIOUS DISEASES 

be vaccinated as a means of prophylaxis, and especially in the 
presence of an epidemic or after exposure. 

Bad results from vaccination are practically always due to care- 
lessness and contagion. Complications due to this should be 
treated according to the standard surgical or medical principles — 
abscesses opened, irrigated, and drained; erysipelas treated with 
serum, etc. 

Revaccination should be done every seven years. The im- 
munity may last for fifteen years, but that period is exception- 
ally long. 

SYPHILIS 

Syphilis requires, in its early stages, thorough treatment with 
mercury; in its later stages the iodids. The reason for this is 
probably that the mercury destroys the active spirochete and is 
useful only so long as they are active, while the iodids break down 
pathological tissues and are therefore indicated when the process 
has reached the gumma and ulcer-building stage. 

The most effective method of administering mercury is by in- 
unction. This is also the dirtiest and most unpleasant, hence a 
constant search is being made to secure another method equally 
efficient. 

To secure good results with inunction one should be very 
methodical. The body should be divided into six areas, as, e. g., 
right arm, right leg, right half of trunk, left arm, left leg, left 
half of trunk. A dram of the officinal mercurial ointment (fifty 
per cent) is rubbed into each of these regions successively for six 
nights. On the seventh a hot bath (with soap) is taken, and on 
the next the course is recommenced. If the mercury be rubbed 
up in lanolin, the skin is made less greasy than if lard and suet 
are used as the base of the ointment. The treatment should con- 
tinue five weeks and then be interrupted for one week and again 
continued for another five weeks. The person who does the rub- 
bing should be protected by rubber gloves. Each inunction should 
take at least fifteen minutes and the ointment should be .rubbed 
completely into the skin. Hairy parts of the body should be 
avoided, lest pustules be formed. Parke, Davis & Co. have re- 
cently devised a little briquette of mercurial ointment (called 



SYPHILIS 385 

mercurette) which has the advantage of ease, cleanliness, and 
exactness of prescription and administration. A prescription for 
the divided paraffin papers follows: 

I? Unguenti hydrargyri 30 grams. 

Mitte in chartulis paraffinatis no. VI. 
Sig. Rub the contents of one packet into the skin every even- 
ing, as directed. 

The next most efficient method of administering mercury is 
intramuscularly. For this purpose oil emulsions of metallic mer- 
cury, solutions of mercuric chlorid, and suspensions of calomel are 
used in hypodermic syringes. Of the soluble preparations, mer- 
cury succinimid, which is put out in tablets of one fifth grain 
each, which are dissolved in sterile distilled hot water as needed, 
is the most used at present. The British army surgeons have used 
this method of treatment more than any other class of men and 
highly recommend it. In general, it has proven of special value 
with those patients who will not or cannot take daily treatment. 

Caille recommends that fifteen drops of the following emulsion 
be used for deep injection into the buttocks: 

If Hydrargyri salicylatis gr. xxij ; 

Olei olivaa Siijss. ; 

Lanolin 3ss. 

M. D. S. Inject every five, six, or seven days. 

Another prescription often used is the following : 

If Hydrargyri chlor. corros 1.0 grams. 

Sodii chloridi 6.0 " 

Aquae destillataa 100.0 c.c. 

Sig. Inject 1 c.c. into the gluteal muscles. 

The most common method of administering mercury is by the 
mouth. At present the yellow iodid of mercury is the favorite 
form and is given in one-fourth-grain tablets or pills three or four 
times a day. The ease of administration rather than its efficiency 
makes for its popularity. The pills or tablets are coated with 
sugar, gelatin, or chocolate, as the physician's fancy may suggest. 
For a simple pill the ordinary prescription might be: 



386 INFECTIOUS DISEASES 

Jy Hydrargyri iodid flavi 0.8 grams. 

Fiat massa et in pilulas numero decern divide. 
Sig. One pill after each meal. 

The treatment with mercury in one form or another should be 
kept up for about three months. Then an interval of a few months 
should be allowed the patient, after which a second but milder 
course should be put through. A third course in the succeeding 
six months is always advisable. 

Insalivation is avoided by cleansing the teeth thoroughly after 
each meal with brush and tooth paste, and by gargling thoroughly 
with hydrogen peroxid at least once a day. The bowels should 
be kept free. Should, however, salivation develop, the adminis- 
tration of mercury should stop at once. 

In the later stages of the disease, potassium or sodium iodid 
should be given with or without mercury. The dose should be at 
least ten grains t. i. d. In obstinate cases as much as ninety grains 
every four hours may be given. With many patients it is sufficient 
to give the drug dissolved in an equal quantity of water, and in 
such case the dose is measured out in drops. In other cases it is 
necessary to use teaspoonful doses, wherefore an appropriate 
vehicle should be used. The compound tincture of gentian with 
water is often used, thus: 

I> Potassii iodidi 15 grams. 

Tct. gentian co 30 c.c. 

Aqua 60 " 

Sig. One teaspoonful t. i. d. 

Another illustrative prescription is: 

I? Potassii iodidi 30 grams. 

Elixiris gentianae glycerinati (N. F.) . . . . 200 c.c. 

Sig. One dessertspoonful after each meal. (The dosage here 
is for a severe case.) 

Sometimes it seems best to give both the iodid and the mer- 
cury. In such cases the best results seem to be obtained when the 
mercury is given intramuscularly or by inunction and the iodid 
by the mouth. 



SYPHILIS 387 

As a minimum we must recommend that during each six months 
a course of treatment should be given until three years shall have 
elapsed. But, better still, whenever practicable the following 
scheme of treatment (Hay) should be adopted with all patients 
who would insure their freedom from the late effect of this ter- 
rible disease: 



Table of Course of Treatment for Five Years 

First Year: 

2 months' inunctions or injections. 

1 month's rest. 

2 months' internal treatment. 

1 month's rest. 

2 months' inunctions or injections. 

1 month's rest. 

2 months' internal treatment. 
1 month's rest. 

Giving eight months' treatment and 4 months' rest. 

Second Year: 

6 weeks' inunctions or injections. 

8 weeks' rest. 

8 weeks' internal treatment. 

4 weeks' rest. 

6 weeks' inunctions or injections. 

8 weeks' rest. 

8 weeks' internal treatment. 

4 weeks' rest. 

Giving total, second year, 7 months' treatment, 5 months' rest. 

Third Year: 

1 month's inunctions or injections. 

1 month's rest. 

1 month's internal treatment. 

1 month's rest, continuing so throughout the entire year, al- 
ternating from internal to injections or rubs. 

Thus giving the total during the third year of 6 months' treat- 
ment and 6 months' rest. 



388 INFECTIOUS DISEASES 

Fourth Year: 

6 weeks' inunctions or injections. 

Fifth Year: 

4 to 6 weeks' inunctions or injections. 

Then one course of treatment of one month each for the next 
five years, thus carrying our patient up to or through the para- 
syphilitic stage. 



PAKT III 

NOTES ON REMEDIES 



CHAPTER I 
MISCELLANEOUS NOTES i 

BATHS IN COMMON USE 

1. The Hot Bath.— Temperature from 98° F. (36.7° C.) to 106° 
F. (41.1° C), or even higher. The cold water should be placed 
in the bath first, and the hot water added until the thermometer 
registers the required temperature. 

2. The Warm Bath.— Temperature 92° F. (33.3° C.) to 98° F. 
(36.7° C). 

3. The Tepid Bath.— Temperature 85° F. (29.4° C.) to 92° F. 
(33.3° C). 

4. The Cold Bath.— Temperature 33° F. (0.6° C.) to 65° F. 
(18.3° C). Accurately defined, a cold bath means a bath at the 
temperature incidental to the time and place without any hot 
water being added. It may be otherwise expressed as water at 65° 
F. (18.3° C), or reduced by gradual addition of ice to 40° F. 
(4.4° C.) or below. 

5. The Alkaline Bath. — Add quarter of an ounce of sodium car- 
bonate to each gallon of water. 

6. The Bran Bath. — Add two ounces of bran to each gallon of 
water. Mix the bran with a small quantity of boiling water, and 
add it to the water in the bath. 

7. The Sulphur Bath. — Add a quarter of an ounce of potassa 
sulphurata to each gallon of water. 

8. The Vapor Bath. — The temperature ranges from 96° F. 
(35.6° C.) to 180° F. (82.2° C). A vapor bath may be impro- 
vised by placing in the bed a few stone ginger-beer bottles, filled 
with nearly boiling water, tightly corked, wrapped around with 

1 Adapted from the Therapeutic Notes of Parke, Davis & Co. 

391 



392 MISCELLANEOUS NOTES 

pieces of flannel wrung out of hot water and placed in the bed 
around the patient, who should be well wrapped. 

9. Turkish Bath. — The temperature ranges from about 120° F. 
(48.9° C.) in the cooler rooms to 230° F. (110° C.) or even higher 
in the hottest room. The best method of taking a Turkish bath is 
to go at once into the hottest room and remain five minutes or 
less; then move into the second room for five minutes; and after- 
wards remain for twenty minutes in the coolest of the three hot 
rooms before being shampooed. By this method the hottest room 
is encountered before there is any heart fatigue. Its high tem- 
perature initiates perspiration, which commences freely in the 
second room, and is continued freely in the third. 

DOSES PROPORTIONATE TO AGE 

According to Young's rule the dose is obtained by dividing the 
age by 12 plus the age. Thus, for a child of three years 8 
=Y5 or T' Cowling's rule is to divide the number of the next 
birthday by 24. Thus, for a child five years old yt— h ^ nar " 
cotics not more than one half of this proportion should be pre- 
scribed, while of cathartics this dose may be exceeded by two or 
three times. Here is Gaubin's dose table, based on 1 grain for the 
adult dose: 

Under one year T V grain 

Under two years £ 

Under three years ^ 

Under four years \ 

Under seven years J 

Under fourteen years ^ 

Under twenty years § 

From twenty-one to sixty years, the full dosage. 

SUBSTANCES EXCRETED IN MILK 

Many substances taken by the mother are excreted in the milk. 
Among these are ammonia and certain aromatic and volatile oils, 
such as the oils of anise, cumin, dill, wormwood, garlic, turpentine, 
and copaiba; the purgative principles of rhubarb, senna, castor 



ALCOHOL TABLE 393 

oil, and seammony; opium, iodin, antimony, arsenic, bismuth, iron, 
lead, mercury, and zinc. The therapeutic actions of certain drugs 
administered to the mother may thus be observed in the child. 
Among these are opium, mercury, arsenic, potassium iodid, senna, 
castor oil, and some other purgatives. 

Substances which increase the flow of milk: Jaborandi, pilo- 
carpin, rich foods, stimulants, and probably thyroid-gland sub- 
stance. 

Substances which lessen the flow of milk: White agaric, bella- 
donna, atropin, ergot, potassium iodid, and sodium iodid. 



ALCOHOL TABLE 

Percentages of alcohol contained in the following liquids 

Rum 60 to 75 

Whisky 50 to 60 

Brandy (British) 50 to 60 

Brandy (French) 50 to 55 

Gin 48 to 60 

Port 18 to 20 

Marsala 15 to 21 

Sherry 18 to 20 

Madeira 14 to 17 

Hungarian Wines 9 to 15 

Claret 8 to 12 

Sauterne 11 to 18 

Burgundy 8 to 14 

Moselle 8 to 12 

Rhine Wines 7 to 16 

Chablis 7 to 10 

Champagne 6 to 13 

Bitter Ale 6 to 9 

Cider 2 to 9 

Porter 4 to 7 

Beer 2 to 4 

Ginger Beer (brewed) 1 to 3 





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394 



METRIC AND APOTHECARIES' EQUIVALENTS 395 



METRIC AND APOTHECARIES' EQUIVALENTS 



Approximate. 



Exact. 



Liquids 

1 minim 

1 fl. dram 

1 fl. ounce 

1 pint 

1 gallon 

1 c.c 

4 c.c 

30 c.c 

470 c.c 

1000 c.c. (1 liter) 

4 liters 

Solids. 

1-509 grain 

1-64 grain 

1 grain 

15 grains 

1 ounce 

1 pound 

1 milligram 

1 gram 

1 decagram 

1 hectogram 

1 kilogram 



0.06 c.c. 
4 c.c. 
30 c.c. 
473 c.c. 
4 liters. 

16 minims. 

1 fl. dram. 

1 fl. ounce. 

1 pint. 
34 fl. ounces. 

1 gallon. 

0.00013 gm. 
0.001 gm. 
0.065 gm. 
1 gm. 
28 gm. 
450 gm. 



15^ grs. 

i oz. 

3^ ozs. 

2* lbs. 



0.061 c.c. 

3.696 c.c. 

29.574 c.c. 

473.197 c.c. 

3 . 785 liters. 

16.23 mins. 

1.082 fl. drs. 

1.014 fl. ozs. 
15.892 fl. ozs. 
33.81 fl. ozs. 

1.056 gals. 



0.000129 gm. 
0.001013 gm. 
0.064798 gm. 
0.972 gm. 
28.350 gm. 
453.592 gm. 

0.015 gr. 
15.432 grs. 
154.324 grs. 
3 ozs. 230 . 7 grs. 
2 lbs. 3 ozs. 120 grs. 



CHAPTER II 

MATERIA MEDICA 

Acidum Aceticum {Acetic Acid) is a liquid composed of thir- 
ty-six per cent of absolute Acetic Acid, HC 2 H 3 2 and sixty-four 
per cent of water. It is a clear, colorless liquid, of a distinctly 
vinegar odor, a purely acid taste, and a strongly acid reaction; 
miscible in all proportions with water or alcohol, and wholly vola- 
tilized by heat. It is prepared from wood by destructive distilla- 
tion and purification. Acetic Acid is also official in two other 
degrees of concentration, viz. : 

Acidum Aceticum Glaciale (Glacial Acetic Acid; HC 2 H 3 OJ 
is nearly or quite absolute Acetic Acid, solid below 59° F., above 
that temperature a colorless liquid. Is strongly escharotic and 
only used locally. 

Acidum Aceticum Dilutum (Diluted Acetic Acid) consists of 
Acetic Acid, 10, Distilled Water, 50 parts; contains six per cent 
of absolute Acetic Acid, and has a sp. gr. of 1.009. It is used 
in the preparation of the two official Aceta (Vinegars). Dose 
TTt xv-3ij [av. TTLxxx]. 

Acetum (Vinegar, unofficial) is an impure dilute Acetic Acid, 
formed by the action of a ferment on a dilute alcoholic liquid, the 
alcohol being oxidized thereby. 

Acetonum (Acetone, Dimethyl Ketone; C 3 H 6 0), a colorless, 
mobile, and volatile liquid, miscible with water, alcohol, etc. It 
is an excellent solvent for resins, gums, camphor, fats, and gun 
cotton, and is employed in the manufacture of some oleoresins and 
of sulphonmethane (sulphonal). (Potter.) 

Aconite (Monkshood, Wolfsbane, Friar's Cowl, Mousebane). — 
Dried tuber of aconitum napellus, L. Ranunculaceae. Found in 
the mountainous regions of Europe, Asia, and North America. 
Contains aconite, aconin, napellin (isoaconitin), pseudoaconitin, 

396 



MATERIA MEDICA 397 

picroaconitin, aconitic acid, fats, and sugar. This is another com- 
plex drug, the chief action of which is the depression of various 
parts of the nervous system. Maximum dose of the fluid extract, 1 
minim; of the tincture, 10 minims. 

Adrenalin (see Epinephrin). 

Aloe, Aloes, is the inspissated juice of the leaves of Aloe vera, 
Aloe Chinensis, Aloe Perryi, or other species of Aloe, a plant of the 
nat. ord. Liliaceie. It occurs in masses of yellowish-brown color, 
fragrant odor and bitter taste, soluble in alcohol and in boiling 
water. It contains a peculiar volatile oil, a resin, and soaloin, 
C 15 H 16 T , a variety of the principle Aloin, which is common to all 
varieties of aloes; also Aloetic and Chrysammic Acids. Dose, gr. 
j-vj [av. gr. jv]. (Potter.) 

Alumen, Alum {Potassium Alum, Aluminum, and Potassium 
Sulphate; A1 2 K 2 (S0 2 ) 4 -f 12 H 2 0) occurs in large, octahedral 
crystals, or cubes, of sweetish astringent taste and acid reaction, 
soluble in 9 parts of water and in 0.3 of boiling water, insoluble in 
alcohol. The Ammonia alum (Alumini et Ammonii Sulphas) was 
formerly official, and is still sold and dispensed as Alum. Dose, 
gr. v-x (av. gr. vijss.) ; as an emetic, 3j for a child. (Potter.) 

Ammonium Salts. — All Ammonium Salts stimulate and finally 
paralyze the spinal cord, motor nerves, and muscles in animals, but 
the order and intensity of the action vary with the salts employed, 
some having a predominating influence on the cord, others on the 
motor nerves. In general, they may be said to form a series, of 
which the members at one end stimulate the cord, and those at the 
other paralyze both the cord and the motor nerves. At the stimu- 
lant end are Ammonia and the Chlorid; at the paralyzant end the 
Iodid; the Bromid, Phosphate, and Sulphate lying between. 
(Brunton.) In medicinal doses they act on man as stimulating 
expectorants, in large quantity they injure the structure of the 
red blood corpuscles, and if long continued they produce rapid 
emaciation by impairing digestion and increasing tissue waste. 
(Potter.) 

Anisum, Anise is the ripe fruit of Pimpinella Anisum, a 
European plant of the nat. ord. Umbelliferas. It occurs in ovate 
bodies, ^ inch long, hairy, of grayish color, aromatic odor, and 
sweet, spicy taste, resembling conium fruit in appearance. Dose, 
gr. v-x [av. gr. vijss.]. 



398 MATERIA MEDICA 

Oleum Anisi (Oil of Anise) is a volatile oil distilled from 
Anise, and represents the medicinal qualities of the plant. It con- 
tains Anethol, C 10 H 12 O, or Anise Camphor, congeals at 50° to 59° 
F., is soluble in an equal part of alcohol, and is an ingredient of 
Tinctura Opii Camphorata, Trochisci Glycyrrhizae et Opii, Aqua 
Anisi, and Spiritus Anisi. Dose, Til j-v [av. ir^iij]. (Potter.) 

Antipyrina, Antipyrin (Phenyl-dimethyl-pyrazolon; C 11 H 12 N 2 0, 
official in the B. P. under the name Phenazonum, Phenazone) , is a 
crystalline substance obtained from the phenyl-hydrazin, and pre- 
pared by a patented and complicated process. It is a synthetical 
base, forming salts which are analogous to those of Ammonium; 
and occurs as colorless and inodorous scaly crystals, with a bitter 
taste, freely soluble in water, alcohol, and chloroform, less soluble 
in ether. It gives a deep red color with ferric chlorid, a deep 
green with nitrous acid, and with nitric acid a yellow color which 
deepens to crimson on warming. Dose, gr. j-x [av. gr. iv]. 
(Potter.) 

Apomorphinae Hydrochloridum (Apomorphin Hydrochlorid; 
C 17 H 17 N0 2 HC1) is the hydrochlorid of the artificial alkaloid Apo- 
morphina, which is prepared from morphin or codein by the action 
of strong acids or zinc chlorid, the morphin losing in the process 
a molecule of water. The salt occurs in minute, colorless crystals, 
odorless, of bitter taste, and neutral or faintly acid reaction ; solu- 
ble in about 45 of water and in the same quantity of alcohol at 
59° P., almost insoluble in ether or chloroform; decomposed by 
boiling water or boiling alcohol. Dose, as an expectorant, gr. ^V" 
inr [av. gr. -jVl ; as an emetic, gr. T V to J [av. gr. T V]. For young 
children gr. ^ should not be exceeded. Solutions should be fresh 
when used, and as they alter rapidly by keeping, should have a few 
drops of hydrochloric acid added to them to prevent decomposition. 

Argyrol (Silver Vitellin) contains thirty per cent of silver, and 
is very soluble in water. It is absolutely painless and nonirritant, 
even in concentrated solutions on the conjunctiva. Solutions of 
two- to ten- or twenty-per-cent strength are used as local astrin- 
gents of 1 to 1,000 for irrigating the vagina, bladder, and urethra. 

Arnica is the dried flower heads of Arnica montana, Leopard's 
Bane, a perennial of the nat. ord. Composite, indigenous to the 
mountains of northern Europe and Siberia, and said to have been 
found in the mountains about the headwaters of the Missouri and 



MATERIA MEDICA 399 

Columbia rivers. It has large orange-yellow flowers and a small, 
curved rhizome with several rootlets. It contains two alkaloids, 
Arnicin and Cytisin, the latter being probably identical with the 
active principle of Cytisus laburnum, the Laburnum; also Tri- 
methylamin (CH 3 ) 3 N, an ammoniacal alkaloidal principle, which 
has been looked upon as the active ingredient. Arnica also con- 
tains Inulin, Capronic, and Caprylic Acids, tannin, mucilage, 
resins, and two essential oils, one in the flowers, the other in the 
root. Dose, gr. v-xx [av. gr. xv]. 

Tinctura Arnica (Tincture of Arnica), strength twenty per 
cent. Dose, Tl\ v-xxx [av. rr^xv]. 

Arsenic. — The primary action of arsenic seems to be that of kill- 
ing epithelial tissue. By epithelial tissue I mean derivatives of the 
embryonal ectoderm. Thus after the giving of arsenic one finds the 
mucous membrane of the intestine necrotic in the form of a fatty 
degeneration; one finds, when further doses are given, that the 
skin, the hair and the nails, the glandular structures, and finally 
the nervous tissues show the arsenic in either the form of arsenites 
or in albuminates. The necrosis is in the form of fatty degenera- 
tion, so that the tissue resembles that following phosphorus poison- 
ing, and appears to be on the way to becoming structureless, sof- 
tened, and more or less white in color. In the intestine this permits 
epithelial layers to slough off in the form of shreds, producing the 
well-known " rice-water " stools. 

Another action very closely allied to the above is that upon the 
capillaries of the splanchnic area. There seems to be the paralysis 
of the vasomotor system, so that the capillaries are dilated and 
flaccid, permitting a free exudation of the serum and gradually 
an edema of the tissues around about them. This action is periph- 
eral rather than central, and must be thought of, I believe, as 
one similar in kind to that upon the mucous membrane of the in- 
testine — essentially a destruction of the trophic power of the cells 
involved. 

The action of arsenic resides in the ion of arsenous acid, there- 
fore the arsenic is innocuous so long as it is not broken up into 
arsenous acid; and in the same way the albuminates of arsenic 
are not only innocuous, but also useless until they have been re- 
duced slowly to arsenous acid, thus liberating the active ion. 

Hence the most active of the medicinal preparations of arsenic 
27 



400 MATERIA MEDICA 

are the solutions of arsenous acid. I believe the next active is the 
arsenic iodid salt, and probably the slowest are the cacodylic-acid 
and the arsanilic-acid preparations. Thus we give thirty drops of 
a ten-per-cent solution of atoxyl hypodermically every third day 
with no toxic symptoms. This dose would in an active preparation 
of arsenic cause a great deal of trouble. It is simply a matter of 
storing up in the system a considerable supply of arsenic, which 
is brought into use by the body tissues by breaking it down and 
making it over into arsenous acid ; hence it would not be at all im- 
possible for some bodies under some conditions to produce toxic 
effects with atoxyl simply because they might break up the drug 
more rapidly than usual. 

From the above, it is easy to understand that arsenic is of con- 
siderable value in affecting the metabolic processes of the body, in 
particular those concerning the ectodermal tissues. On the old 
principle that those drugs which cause a necrosis or paralysis when 
administered in large doses, in minor doses stimulate, we may, by 
utilizing minor doses of arsenic, secure a stimulating effect on the 
cells of the ectodermal tissues as far as their nutrition is concerned. 
Thus, if we wish to make a horse's coat of hair look glossy, we give 
him arsenic to stimulate the ectodermal nutrition ; when a woman 
wishes to whiten her complexion, making the skin cells fuller, 
rounder, and glossier, she uses arsenic; when we wish to stimulate 
the nutrition of the intestinal mucosa, we give arsenic in doses just 
strong enough to stimulate the nutrition of the nerve fibers and 
cells ; hence the use of arsenic in anemia is not so much the replac- 
ing the hemoglobin or even the corpuscular elements of the blood 
as it is the stimulation of the nutritional forces governing the 
blood supplies. 

The drug is not useful in all skin diseases. Referring to the 
physiologic action outlined above, we can readily see why it is of 
use in only those conditions wherein the nutrition of the dermal 
structures is involved; therefore in acute inflammatory conditions 
it would be contraindicated, because there is already a hyperactiv- 
ity of the nutritional centers, and the only need is one of sedation 
rather than stimulation. If, however, we had a rough, dry skin 
before us, showing a lack of cell growth, of smoothness in the cell, 
of fullness of development, and we could not find the cause in 
some extraneous or external irritation, we would be justified in 



MATERIA MEDICA 401 

prescribing arsenic in doses strong enough to stimulate dermal 
growth. 

The use of arsenic in inoperable cancer is theoretically justifi- 
able, because a cancer is an epithelial product and the cells of can- 
cer are of lesser resistance than the cells of the normal tissue. 
Therefore, if Ave should give arsenic in doses just strong enough to 
destroy the pathologic cells but not the normal ones, we would 
be following exactly the same principle of treatment that we em- 
ploy in using the X-ray. We cannot employ heavier doses because 
if we should give the arsenic locally hypodermically, it would 
spread throughout the body and give toxic effects, and if we em- 
ploy it in the form of paste we cannot regulate its strength well 
enough to make it destroy the pathologic and leave untouched the 
normal cells. 

Asafetida: Mistura Magnesias et Asafoetidae (DeWees' Carmina- 
tive). — Each fluid ounce contains 24 grains magnesium carbonate, 
1 fluid dram tincture asafetida, and 5 minims tincture opium. 
Dose, \ to 1 fluid ounce (16 to 32 c.c). 

The magnesia in this mixture is valuable chiefly as an alkali, 
while the asafetida is a gastric stimulant. This latter drug has 
come down to us from ancient Hindu and Persian medicine. It is 
a gum resin from the root of the ferula fcetida (Umbelliferas) 
growing in Turkestan and Afghanistan. It contains three to nine 
per cent volatile oil, twenty to thirty per cent gum, forty-five to 
seventy per cent resin. The alcoholic preparations yield turbid 
mixtures with aqueous fluids. The tincture of asafetida is twenty 
per cent strength and may be used in 1-c.c. (15-drop) doses. The 
milk of asafetida (the officinal emulsion) is four per cent strength 
and should be used in tablespoonful (4-dram, 16-c.c.) doses. The 
officinal pill contains 3 grains and two are usually given at a dose. 
Some surgeons give a suppository containing 3 grains of asafetida 
after a laparotomy in order to prevent abdominal distention. 

Atropin (Atropina; C 17 H 23 N0 3 = 287.04), an alkaloid obtained 
from atropa belladonna and other plants of the same family 
(Fam. Solanacese). White, odorless, bitter, acid crystals. Soluble 
in 450 parts water, 1.46 alcohol, 16.6 ether, 1.56 chloroform, and 
50 glycerin. Average dose, y^-g- gr. (0.0004 gm.). Applied locally 
as the oleate. Antidotes: morphin, pilocarpin, physostigmin, or 
aconitin. 



402 MATERIA MEDICA 

There is a large group of drugs used in medicine which de- 
pend for their activity on an atropin-like substance, and it has 
been found that the bases of most of these are the same; that is, 
the tropins and oscins. The tropins and oscins themselves are 
practically inactive. Their derivatives, however, tropeins and 
osceins, are very active agents. Atropin is isomeric with hyos- 
cyamin, but it is optically inactive, while the latter turns the spec- 
troscope to the left. Atroscin is isomeric with scopolomin, but is 
also optically inactive. The two mixed, atroscin and scopolomin, 
produce hyoscin, hence hyoscin is a difficult drug to use because 
we are never sure just which action we may expect. The names 
of the principal plants from which these drugs are derived are 
the atropa belladonna, the datura stramonium (from which the 
stramonium for burning is derived), hyoscyamus niger or hen- 
bane, duboisia myroporoides, mandragora autumnalis (mandrake), 
scopola atropoides. 

The group action of atropin excites first and then paralyzes the 
cerebral centers. It paralyzes the end nerves of glands, pupils, 
the unstriped, and also the cardiac muscle. It slightly stimulates 
and then paralyzes the smooth and cardiac muscle directly. Fi- 
nally, it paralyzes the sensory nerve endings when locally applied. 
Thus atropin dilates the pupil by paralyzing the oculomotor nerve 
endings, while cocain dilates the pupil by stimulating the sym- 
pathetic. 

Atropin is rapidly excreted in the urine, and therefore in cases 
of poisoning the fate of the patient is known within a few hours. 
In fact, because of this rapid excretion, rarely does anyone die 
from atropin poisoning. The drug is used either as the tincture 
of belladonna (ten per cent, dose 5 to 15 drops), or as atropin in 
doses of t^o" to §V of a grain. 

Benzoinum, Benzoin, a balsamic resin obtained from Styrax Ben- 
zoin Dryander and another unidentified species of Styrax (Fam. 
Styraceas) . In pebble-like bodies or tears, mostly 0.5 to 5 cm. long 
and about one fourth as thick, slightly flattened, straight, or curved, 
yellowish to rusty brown externally, milky white on fresh frac- 
ture, separate or very slightly agglutinated (Siam Benzoin) or 
embedded in a dry resinous mass, which varies from reddish brown 
to reddish gray or grayish brown; opaque or slightly translucent 



MATERIA MEDICA 403 

and more or less lustrous (Sumatra Benzoin) ; brittle, becoming 
soft on warming, and yielding benzoic acid on sublimation; odor 
agreeable, balsamic (vanilla-like in the Siam variety) ; taste 
slightly acid. 

Benzoin is almost wholly soluble in five parts of warm alcohol, 
the solution showing an acid reaction to blue litmus paper ; soluble 
in solutions of sodium or potassium hydroxid. Average dose, 1 gm. 
(15 grains). (U. S. P.) 

Adeps Benzoinatus (Benzoated Lard), Lard, 1,000 grams; 
Benzoin in coarse powder, 20 grams. (U. S. P.) 

Berberis (Barberry), the dried rhizome and roots of Berberis 
aquifolium and other species of berberis (Fam. Berberidaceag), 
North America. This is akin to the berberin found in golden seal. 
It is a bitter yellow drug and is generally given in the fluid ex- 
tract in a dose of 2 c.c. The bitter principle, berberin, is found 
in many of the drugs used in domestic medicine, hence the sus- 
picion is justified that they depend for their value on its presence. 
Thus xanthoxylum and hydrastis, both of reputation as tonics, 
contain berberin. (Sollmann.) 

Bismuth. — It should always be kept in mind in dealing with 
this drug that there are two classes of bismuth salts, the soluble 
and the insoluble. The soluble salts are rarely used in medi- 
cine. When introduced into the system they produce the arsenic 
phenomena with a depression of the central nervous system and 
also of the cardiac muscles. The insoluble salts, on the other 
hand, when free from contamination are practically innocuous 
and present only the local effects. These are the basic or oxy salts. 
They are used externally for dusting on wounds, where they pro- 
duce a dry scab under which the healing process may go on free 
from external irritation. Not only on this account are they valuable, 
but also because they dry up the secretions in and about the 
wounds, thus depriving any bacteria that might be present of nu- 
trient media. On account of this property, bismuth subnitrate has 
even been injected into the urethra to check the secretions and 
reduce inflammation in cases of acute urethritis. When given by 
the mouth, the basic salts have a tendency to neutralize the ex- 
cessive acidity of the stomach. They are also valuable in cases of 
vomiting and diarrhea and for intestinal putrefaction. In the 
latter case they are best given with salol. 



404 MATERIA MEDICA 

In the intestinal canal bismuth subnitrate combines with the 
sulphids there present and produces a black color in the stools 
which has sometimes been confounded with that due to hem- 
orrhage. 

When combined with iodin (as in the proprietary preparation 
airol) they are perhaps still more antiseptic and therefore better 
dusting powders. A similar combination for use in the intestinal 
canal is that with the phenols ; for example, we have tribromphenol 
(xerofrom), a yellow powder containing sixty per cent bismuth, 
insoluble in water; and the combination with the betanaphthol 
(orphol), a grayish powder of unpleasant taste and odor of 
naphthol. 

The preparations most in demand are: 

Bismuth Subnitrate (Bismuthi Subnitras, Magistery of Bis- 
muth, Bismuth Oxynitrate; BiN0 3 H 2 0), white, odorless, heavy, 
almost tasteless, insoluble in usual solvents. Incompatible with 
gallic acid, salicylic acid, and tannin. 

When bismuth subnitrate is pure and free from arsenic, it may 
be given in almost unlimited doses, because it can have no toxic 
effects unless absorbed. The dose, therefore, varies greatly, the 
minimum being probably 3 to 5 grains (0.2 to 0.3). 

Bismuth Subcarbonate (Bismuthi Subcarbonas; (BiO) 2 C 7 - 
H 5 5 ), stomachic, intestinal astringent. This is a combination of 
bismuth subnitrate with sodium bicarbonate. The dose for internal 
use is J gram (7f grains). 

Acidum Boricum (Boric Acid, Boracic Acid; H 3 B0 8 ) is a weak 
acid occurring in transparent, colorless, six-sided plates, of unctu- 
ous touch, odorless, of a cooling and slightly bitter taste, soluble in 
25 of water, in 15 of alcohol, and in 10 of glycerin. Its aqueous 
solubility is increased by the addition of hydrochloric acid or 
borax. It is produced from Borax by the action of sulphuric acid ; 
also by the purification of the native acid. Dose, gr. v-xv [av. 
gr. vijss.]. There are two official Borates, viz.: 

Sodii Boras (Sodium Borate, Borax; Na 2 B 4 7 + 10 H 2 0), col- 
orless, transparent prisms, of cooling and sweetish, afterwards 
alkaline, taste and alkaline reaction, soluble in 16 of water at 59° 
P., and in 0.5 of boiling water; insoluble in alcohol. Occurs native 
in ancient lake beds in Death Valley region, California, and various 
other parts of the world. Dose, gr. v-xxx [av. gr. vijss.]. 



MATERIA MEDICA 405 

Glyceryl Borate (Boroglycerin), official in the following 
preparation : 

Glyceritum Boroglycerini (Glycerite of Boroglycerin), pre- 
pared by heating together Boric Acid, 310, and Glycerin, 460, until 
reduced to 500 grams, then adding an equal weight of Glycerin. 

Liquor Antisepticus (Antiseptic Solution), contains of Boric 
Acid, 2 ; Benzoic Acid, 0.1 ; Thymol, 0.1 ; Eucalyptol, 0.025 ; Oil of 
Peppermint, 0.05; Oil of Gaultheria, 0.025; Oil of Thyme, 0.01; 
Alcohol, 25; Purified Talc, 2; Water to 100. Dose, 3ss.-ij [av. 5j]. 

Unguentum Acidi Borici (Ointment of Boric Acid) has of 
Boric Acid, 10; Paraffin, 10; White Petrolatum, 80. 

Bromids. — Potassii Bromidum (Potassium Bromid; KBr), col- 
orless, cubical crystals, soluble in 1.6 of water and in 200 of alcohol. 
Dose, gr. ij-3j [av. gr. xv], well diluted. 

Sodii Bromidum (Sodium Bromid; NaBr), colorless, monoclinic 
crystals, soluble in 1.2 of water and in 13 of alcohol. Dose, gr. ij 
-3j [av. gr. xv], well diluted. 

Lithii Bromidum (Lithium Bromid; LiBr), a white, granular, 
deliquescent salt, very soluble in water and in alcohol. Dose, gr. 
ij-xl [av. gr. xv], well diluted. 

Ammonii Bromidum (Ammonium Bromid; NH 4 Br), colorless, 
prismatic crystals, soluble in 1.5 of water and in 30 of alcohol. 
Dose, gr. ij-x [av. gr. xv], well diluted. This Bromid is well 
borne by children in comparatively large doses if epileptic from 
reflex causes. A child one year old can tolerate gr. v every four 
hours. (Barton.) 

Calcii Bromidum ( Calcium Bromid; CaBr 2 ) , a white granular, 
deliquescent salt, very soluble in water and in alcohol. Dose, gr. 
ij— 3j [av. gr. xv], well diluted. 

Strontii Bromidum (Strontium Bromid; SrBr 2 (H 2 0) 6 , color- 
less, hexagonal crystals, very deliquescent, very soluble in water 
and in alcohol; insoluble in ether. Dose, gr. ij-xxx [av. gr. xv], 
well diluted. 

Zinci Bromidum (Zinc Bromid; ZnBr 2 ), a white, granular, 
deliquescent powder, very soluble in water and in alcohol. Dose, 
gr. £-iij [av. gr. ij], well diluted. 

Bromids are rapidly absorbed and slowly eliminated by the 
kidneys, skin, saliva, intestinal and bronchial mucous membranes, 
and the milk. They irritate the mucous membranes at the points 



406 MATERIA MEDICA 

of elimination, and increase the quantity of the urine and the 
excretion of the chlorids and the nitrogenous constituents, but de- 
crease the elimination of the phosphates. 

Hydrobromic Acid is more irritant to the stomach than the 
bromids, but after absorption it has the same action as these 
agents on the nervous system and the circulation. 

Difference in Action Behveen the Bromids. — Potassium Bromid 
is the most toxic to the heart and the muscular system, and is the 
least hypnotic. It contains sixty-six per cent of bromin. 

Sodium Bromid is the least toxic, but the most hypnotic, and 
acts more energetically on the circulation. It contains seventy- 
eight per cent of bromin. 

Ammonium Bromid resembles the Potassium salt in action, ex- 
cept that it exerts less influence on the heart and on the muscular 
system, and is somewhat more stimulating. 

Lithium Bromid contains the most Bromin (ninety-two per 
cent) and resembles the sodium salt in action. It has proved better 
than the others in some cases of epilepsy, and is by several authori- 
ties considered the best hypnotic of the series. 

Calcium Bromid is an efficient hypnotic, but otherwise much 
less active than the other bromids. 

Strontium Bromid is said to be less apt than the other bromids 
to produce the bromic acne and the other results of bromism. 

Zinc Bromid, in large doses, is violently irritant. It is sup- 
posed to combine the tonic effects of zinc with the sedative action 
of the bromids. (Potter.) 

Bromural is a nerve sedative which is claimed to produce sleep 
without markedly affecting the circulation or respiration. All 
action by bromural is said to cease after from three to five hours. 
In many cases, however, the sleep caused by the preparation con- 
tinues beyond the limits of its action. Bromural does not produce 
the desired effects in cases of insomnia where pain, cough, angina 
pectoris, and excitement or delirium exist. It is given as a nerve 
sedative in doses of 0.3 gram (5 grains) three times daily, as a 
soporific at bedtime 0.6 gram (10 grains), which dose may be re- 
peated if needful during the night, after the action of the first dose 
has ceased. 

Bromural is supplied as a powder and also in tablets of 0.3 
gram (5 grains) each. 



MATERIA MEDICA 407 

Oleum Cadinum (Oil of Cade, Empyreumatic Oil of Juniper) 
is a product of the dry distillation of the wood of Juniperus oxy- 
cedrus. It is a tarlike substance of uncertain composition and pur- 
ity, insoluble in water, partially soluble in alcohol, completely so 
in ether, chloroform, or carbon disulphid. Used locally as a stimu- 
lant. (Potter.) 

Caffein (Caffeina, Coffeine, Thein, Guarananine, Trimethyl- 
xanthine; C 10 H 10 N 4 O 2 H 2 O = 210.64), alkaloid from dried leaves of 
thea senensis (Fam. Ternstroemiacese), or dried seeds of coffea 
arabica (Fam. Rubiaceae). White, silky, odorless, bitter needles. 
Soluble in 45.6 parts water, 53.2 alcohol, 375 ether, 8 chloroform. 
Aqueous solubility is increased by potassium bromid, sodium ben- 
zoate, sodium salicylate. Average dose: 1 grain (0.065 gram). 

This is one of the xanthin bodies. Its action in general is to 
increase the nervous irritability of the central nervous system 
from above downward, in contrast to strychnin, which acts from 
below upward. It increases muscular contraction (like alcohol) 
even to the point of rigor — that is, to the point of the loss of elas- 
ticity. It has a diuretic action through its local influence on the 
renal functions. 

Expressed differently, the effect of the drug is to produce a 
quicker flow of blood and a release from drowsiness. Its action 
on the respiration and circulation is similar to that of strychnin, 
but weaker. The spinal cord is affected only by heavy doses. 
Since its action affects not only the medulla, but also the vagus 
and vasomotor centers, the effect on the circulation will vary from 
patient to patient and from time to time. It is rapidly absorbed 
and easily broken up in the body. 

Of the xanthin group, caffein has the strongest action on the 
nervous system. Paraxanthin is the most diuretic, then theophyllin 
(theocin), then theobromin, and lastly caffein. The action of the 
members of the group on striped muscle is parallel to the diuresis. 

Of the crude drugs containing these bodies, coffee contains 1 
to 3 per cent caffein — that is, an ordinary cup of coffee would con- 
tain 0.1 to 0.2 per cent of caffein. Tea shows 1J to 4 per cent 
caffein; cola, 2 per cent; guarana, 4 to 5 per cent (3-J per cent 
U. S. P.) ; mate, T \ to l T 6 o per cent. 

The preparations of this drug are not chemical compounds, but 
simple mixtures. Thus: 



408 MATERIA MEDICA 

Caffein Citrated contains 50 per cent caffein and 50 per cent 
citric acid, and is soluble in 25 parts water. This mixture is made 
in order to make the practically insoluble caffein somewhat more 
soluble. The dose of caffeina citrata is 0.15 to 0.5 gram. 

Caffein Citrata Effervescens contains only two per cent caf- 
fein, and should be used in dosage of 4 to 15 grams. 

Caffein Sodio-benzoas and 

Caffein Sodio-salicylas contain 50 per cent caffein, the double 
salt being used to obtain greater solubility and permanence. 

Pulvis Acetanilidi Compositus contains 10 per cent caffein 
wherein the caffein is used to counteract the depressant effects of 
the acetanilid. 

Because of its limited solubility, caffein itself may not be used 
subcutaneously, and therefore probably is as effective in the form 
of hot coffee as in any other way. But where the hypodermic use 
of caffein is needed the sodio-benzoate (now called " caffein and 
sodium benzoate ") is preferred in doses of 2 to 3 grains. Caffein 
is, of course, not to be used in cases of high blood pressure. 

Calcium (Ca) is the metal characteristic of lime, chalk, and all 
calcareous substances, and although itself unofficial it is repre- 
sented by several official salts and preparations. Lime (calx) and 
chalk (creta) are respectively the oxid (CaO) and the carbonate 
(CaC0 3 ) of calcium, the carbonate occurring in the native forms 
called chalk, marble, limestone, oyster shells, etc., which are con- 
verted into lime by heating to full redness (calcination), thereby 
driving off carbonic acid and leaving the oxid behind. The lat- 
ter, in this form, is known as " burnt lime " or " quicklime," 
and by the addition of one half or three fourths its weight of 
water, combines with one molecule of H 2 to form calcium hy- 
droxid, Ca (HO) 2 , or " slaked lime," the process being termed 
" slaking " and being accompanied by the evolution of a high de- 
gree of heat. 

Liquor Calcis (Solution of Calcium Hydroxid, Lime Water) 
contains not less than 0.14 per cent of calcium hydroxid 
Ca(HO) 2 . A clear, colorless liquid of saline taste and alkaline re- 
action. Dose, o ss ~J [ av - 3iv], 

Creta Pr^eparata (Prepared Chalk; CaC0 3 ) is native calcium 
carbonate, freed from most of its impurities by elutriation ; a white, 
amorphous powder, odorless and tasteless, insoluble in water or 



MATERIA MEDICA 409 

alcohol. Dose, gr. x-xxx [av. gr. xv]. It is a constituent of Hy- 
drargyrum cum Creta, and also of the following: 

Pulvis Cret.e Compositus (Compound Chalk Powder) has of 
prepared chalk, 30 parts; acacia, 20 parts; sugar, 50 parts. Dose, 
gr. v-3j [av. gr. xxx] . 

Mistura Cret^ (Chalk Mixture) has of the preceding 20 parts, 
cinnamon water 40, water to 100, rubbed together and made fresh 
as required. Dose, 3j-§j [av. 3iv]. (Potter.) 

Camphor. — This is one of the stereoptenes and is a solid de- 
posited from a volatile oil. To this group belong: 

Turpentine (C 10 H 16 ), 
Camphor (C 10 H 16 O), 
Camphoric acid (C 10 H 16 OJ, 
Bromate of camphor (C 10 H 18 O), 
Menthol (C 10 H 20 O), 
and others. 

The action of camphor in general is similar to that of carbolic 
acid, but more stimulant, especially to the medulla. It stimulates 
the vasomotor centers, the cardiac muscle, and produces an effect 
on the endings of the sensory nerves (sensation of cold in the case 
of menthol). Ordinarily there is a peripheral depression of the 
tonus of the blood vessels. It acts as a mild antiseptic. In contra- 
distinction to strychnin it acts more on the medulla and brain 
than on the cord. It is readily absorbed and broken up into the 
hydroxyls in the tissues. It is used hypodermically in nervous 
spasms and circulatory depression, and is given by the mouth for 
colds and similar conditions. It is sometimes used for local anes- 
thesia, and has been given for dyspeptic conditions both for its 
antiseptic as well as its stimulant effect. (Sollmann.) 

The best camphor comes from China and Japan. The dose 
of the crude drug is 0.05 to 0.3. 

Aqua Camphors is the saturated solution, and is used in doses 
of 8 c.c. The spirits of camphor form a ten-per-cent solution. 

Monobromated Camphor (C amphora Monobromata, Bromcam- 
phor), bromin substitution product of camphor, colorless needles 
or scales of mild camphoraceous odor and taste. Almost insoluble 
in water; freely soluble in alcohol, ether, chloroform, and oils. 
Sedative, antispasmodic, antineuralgic. Average dose, 2 grains. 



410 MATERIA MEDICA 

Incompatible on trituration with butyl-chloral hydrate, chloral 
hydrate, phenol, menthol, beta-naphthol, resorcin, salol, salicylic 
acid, thymol, and urethane. It is used in cases of mild insomnia. 

Linimentum Camphors is a twenty-per-cent solution in cotton- 
seed oil. The officinal cerate is a ten-per-cent preparation. The 
compound tincture of camphor is the paregoric mentioned under 
opium. Camphor and chloral when rubbed together in equal parts 
form an oil combination which has a very sedative effect and may 
be used for dropping in the external ear to soothe the pain of 
otitis media. 

Oxy Camphor (camphor in which H is replaced by OH) is 
used in a fifty-per-cent solution (alcoholic) in dose of 1 c.c. as a 
respiratory cough sedative. 

Camphoric Acid is used in dosage of 0.6 to 2 for night sweats 
in phthisis. It does not seem to be very efficient, and ordinary 
agaracinum (from the Boletus Laricis) in doses of 0.005 to 0.3 is 
preferable. 

Menthol may be given in doses of 0.02 to 0.12 (av., 1 grain). 

Phenolated Camphor is a mixture of equal parts of phenol 
crystal and camphor gum. It is useful as an antiseptic and in dis- 
infecting wounds and abscesses, and is also useful in injecting 
hypodermically into inflamed hemorrhoids to produce a gradual 
sloughing. For this latter purpose the dose should be 1 to 5 drops. 
(Sollmann.) 

Carbo Animalis {Animal Charcoal), prepared from bone, occur- 
ring in dull black fragments or powder, odorless and nearly taste- 
less, insoluble in water or alcohol. 

Carbo Ligni {Charcoal), prepared from soft wood, and very 
finely powdered, is black, shining, brittle, inodorous, tasteless, and 
insoluble. Dose, gr. x-xx [av. gr. xv]. (Potter.) 

Cardamomum {Cardamom) is the dried fruit of Elettaria. re- 
pens, a plant of the nat. ord. Zingiberacea?, cultivated in Malabar. 
It contains about four and a half per cent of a volatile oil (C 10 H 1G ) 
isomeric with oil of turpentine, the oil being the active principle; 
also a fixed oil, coloring matter, etc. It is an ingredient of pulvis 
aromaticus and of fluidextractum aromaticum, as well of several 
compound preparations. Dose, gr. x-xx [av. gr. xv]. 

Tinctura Cardamomi {Tincture of Cardamom), twenty per 
cent. Dose, 3ss-jss [av. 5j]. 



MATERIA MEDICA 411 

Tinctura Cardamomi Composita (Compound Tincture of Car- 
damom) has of cardamom 25, cinnamon 25, caraway 12, cochineal 5, 
glycerin 50, diluted alcohol to 1,000 parts. Dose, 3ss.-jss. [av. 3j]. 

Cascara Sagrada, Rhamnus Purshiana (Chittem Bark, Sacred 
Bark) is the bark of rhamnus purshiana, the California buck- 
thorn, a small tree of the nat. ord. Rhamnaceae, growing on the 
Pacific coast of the United States. It contains a volatile oil, a 
neutral crystalline substance, several resins, with tannic, malic, and 
oxalic acids. It has been found very serviceable in the treatment 
of chronic gout and chronic constipation, given in gradually dimin- 
ished doses. It produces large, soft, and painless evacuations, and 
the bowels are said to act naturally and regularly after its disuse. 
Dose, gr. x-xxx [av. gr. xv]. 

Another species of the same order, rhamnus frangula, is official 
under the title frangula. 

Extractum Rhamni PuRSHiANiE (Extract of Cascara Sa- 
grada). Dose, gr. j-vj [av. gr. iv], 

Fluidextractum Rhamni Purshiana (Fluidextract of Cas- 
cara Sagrada). Dose, TTt x-xxx [av. Tr\, xv]. 

Fluidextractum Rhamni Purshiana Aromaticum (Aromatic 
Fluidextract of Cascara Sagrada). Dose, Tl^ x-xxx [av. n\xv]. 
(Potter.) 

Castor Oil, Ricini Oleum, is a fixed oil expressed from the seeds 
of Ricinus communis, a tree of the nat. ord. Euphorbiaceae, indige- 
nous to India, but extensively cultivated in the United States. 
The oil is an almost colorless, transparent, viscid liquid, of faint 
odor, bland or slightly acrid taste, neutral reaction, soluble in an 
equal weight of alcohol. It consists mainly of ricinolein, the 
glycerid of ricinoleic acid, also palmitin, stearin, and myristin in 
small quantities, and an acrid principle. The seeds contain a 
highly toxic ferment or phytalbumose named ricin, and an alka- 
loid (ricinine) which seems to be inert. Dose, 3ij-§j [av. 3iv]. 

The nauseous smell is best concealed by the essential oil of bit- 
ter almonds. Emulsions are not a success. Capsules containing 
the requisite dose are easily obtained. In the absence of these the 
best way to administer a dose of oil is to smear the sides of a clean 
wineglass with very thick cream, then pour in the oil, covering it 
with a little more cream. A teaspoonful of cream being then 
taken into the patient's mouth, he is directed to bolt the dose at 



412 MATERIA MEDICA 

one gulp. Some prefer it floated on orange juice, strong coffee, 
gruel, or wine. One of the best vehicles for it is foaming beer. 
Glycerin increases its purgative power when given conjointly. If 
the mouth be chilled by broken ice immediately before taking the 
oil, the taste of the latter will be imperceptible. (Potter.) 

A pleasant preparation is sold under the trade name of laxol. 

Chloral Hydrate is a trichloraldehyd : 

CH3COH CCI3COH CCl 3 COH.H 2 

— Ethyl aldehyd. = Chloral. = Chloral hydrate. 

This substance was discovered by Liebig in 1831 and introduced as 
a hypnotic by Liebreich in 1868. He assumed that it was decom- 
posed in the organism, as it is by the action of alkalies in the test 

tube : CCI3OH + KOH = CHC1 3 + KC0 2 H 

Chloral. Chloroform. Pot. formate. 

This is not the case, the chloral being excreted for the most part 
as trichlorethyl-glycuronic acid. This latter reduces Fehling's so- 
lution, which gave rise to the erroneous assertion that chloral causes 
glycosuria. A small portion of the chloral is excreted unchanged, 
while a fraction is decomposed, being excreted as chlorids. 

Chloral is soluble in water, alcohol, ether, and glycerin. Its 
melting point is 58° C, and it boils at 97° C. Heavy doses depress 
the medulla and slow the respiration and lower the blood pressure. 
It may, like chloroform, paralyze the heart, but fatal effects are 
more apt to be due to the depression of the medullary respiratory 
center. Chloral causes a more rapid destruction of proteid. Lo- 
cally it is a rubefacient. 

A mixture of chloral and bromid is sometimes used as follows : 

ty Chloral hydrate (0.8) 200 grams. 

Potassium bromid (0.8) 200 " 

Ext. cannabis indica (0.008) 2 " 

Ext. hyoscyamus (0.008) 20 " 

Pumice 2 " 

Water q. s. ad (4.0) 1000 c.c. 

(Mistura chlorali et potassii bromidi composita of the National 
Formulary.) 

One teaspoonful is the usual dose. 



MATERIA MEDICA 413 

Chloretone (Acetone Chloroform) is a trichlor- tertiary butyl- 
alcohol, obtained by the action of caustic potash on equal weights 
of acetone and chloroform. It occurs as a white crystalline powder 
of camphoraceous odor, sparingly soluble in water, very soluble in 
alcohol, in ether, and in chloroform. Dose, gr. v-xxx. 

Chloroformum (Chloroform, Trichloro-methane; CHC1 3 ). — Ab- 
solute chloroform is formed by the substitution of three atoms of 
chlorin for three of hydrogen in marsh gas, methyl hydrid (CHJ, 
and is obtained by the action of chlorinated lime on ethylic or 
methylic alcohol, or by that of an alkaline hydrate on chloral. If 
prepared from methylic alcohol (wood spirit) it is called methylic 
chloroform, and is purified with great difficulty. The object of its 
purification is the removal of the chlorinated pyrogenous oil. The 
official form is: 

Chloroformum (chloroform) is a liquid consisting of 99 to 99.4 
per cent by weight of absolute chloroform, and 0.6 to 1 per cent 
of alcohol. A heavy, clear, colorless, mobile, and diffusible liquid, 
of characteristic, ethereal odor, a burning, sweet taste, neutral 
reaction; volatile, not inflammable; soluble in 200 volumes of 
water, freely so in alcohol and in ether, also in oils, benzol, and 
benzine. Sp. gr. not below 1.490 at 59° F., or 1.476 at 77° F. 
Dose, internally, TTL ij-x [av. n\ v] ; for inhalation, 5ss-j, repeated 
until the desired effect is produced. (Potter.) 

Acidum Citricum (Citric Acid; H 3 C 6 H 5 7 + H 2 0) is obtained 
from the juice of the lemon or the lime by adding chalk to form cal- 
cium citrate, which is then decomposed by dilute sulphuric acid. It 
occurs in colorless, rhombic crystals which are very soluble in water. 
A solution of gr. xvij in §ss of water corresponds to §ss of fresh 
lemon juice, and this quantity of either will neutralize of potas- 
sium bicarbonate gr. xxv, of sodium bicarbonate gr. xx, and of 
ammonium carbonate gr. xivss. Dose, gr. v-xv [av. gr. vijss]. 

Citrates of bismuth, bismuth and ammonium, iron, iron and 
ammonium, iron and quinin, iron and strychnin, lithium, magne- 
sium, potassium, and sodium, ten in all, are officinal. 

Coal-tar Derivatives. — Their origin is to be traced back to a desire 
to obtain a cheap substitute for quinin, resulting first in Kolbe's pro- 
ducing synthetic salicylic acid from phenol, and Knorr's discovery of 
antipyrin. After this, a new group of drugs owed its origin to the dis- 
covery, by Cohn and Hepp, that anilin (C 6 H 5 NH 2 ) had very great 



414 MATERIA MEDICA 

antiseptic properties and could be used in the less dangerous form of 
acetanilid (found by Gerhard in 1852), which was quickly patented in 
Germany under the name of " antif ebrin " and exploited. But still its 
effects were too marked (collapse and methemoglobinuria) and too dan- 
gerous, so that phenacetin (acetphenetidin, Hinsberg), also patented 
and exploited, was soon introduced by Kast and Baumler. All the vari- 
ous medicinal antipyretics and so-called specifics are the result of these 
three bodies — salicylic acid, antipyrin, and phenacetin, and therefore 
acetanilid — by the changes produced in the molecules of one of them, 
either by combination of salicylic-acid molecules or with some other 
organic molecule. It would be impossible, in this connection, to give 
all the various combinations that have been produced; a few of the 
more common ones may be mentioned: From salicylic acid, salol, salo- 
phen, aspirin; from antipyrin, salipyrin, pyramidon; from phenacetin, 
salophen, lactophenin, citrophen, exalgin, malakin, kyrofin, and pheno- 
coll. As for the effects of these drugs, they are the resultant of the 
parent drug or drugs, and depend upon the rapidity with which they 
are changed to these primary drugs in the system and the number of 
molecules of the parent drugs in the combination. In so far as the 
former is accomplished good has been done, especially in the acetanilid, 
the antipyrin, and phenacetin combinations. But the dose must be in- 
creased so that, with the increasing avidity of the manufacturers in 
introducing new compounds, the parent molecule will be finally repre- 
sented in such small quantity that it will have no effects; only such 
effects will be noticed as are produced by the substituting molecule, or 
the change will go on so slowly that no general effects can be noticed, 
unless the medicine is given in enormous doses — a desideratum much 
sought by the manufacturers. Every physician is flooded with an- 
nouncements of these new combinations, frequently, unfortunately, 
signed by men of eminence in the profession. How can he best perform 
his duty to his patients and to himself? To his patients, in neglecting 
the use of a drug which might do good; to himself, in not having done 
this and in being looked upon as a nonprogressive man for failing to 
use a new drug which his neighbor has used with such eminent success ? 
The matter is perfectly simple ; learn to use that drug which is followed 
by the best results — i. e., by prompt action and the minimum amount 
of damage — and use this drug until satisfied that something better has 
been offered. In adhering to one drug, the administration and effects 
of which are thoroughly understood by the physician, both he and his 
patients will fare better than by taking up new, unknown drugs, whose 
number promises to be without end. In influenza many of these pro- 
duce good effects for the nervous, the gastrointestinal, and the febrile 
symptoms; not any of them is a specific, notwithstanding statements to 



MATERIA MEDICA 415 

the contrary. It must be remembered that phenacetin derivatives pro- 
duce collapse and blood changes; that acetanilid should never be used 
at the present day; that synthetic salicylic acid produces most un- 
pleasant and sometimes fatal heart complications; and that antipyrin, 
especially in fever, may produce collapse. It is wrong, therefore, to 
use any of them in continued fevers in large doses, because of their bad 
effects, because the cause of the lesion is not removed — indeed, there is 
a retention of it in the blood — and because the recovery of the patient 
is postponed. When the temperature produces dangerous symptoms not 
to be removed by other means, they should be used. In hyperthermia 
in diseases in which the febrile course is very short, they may be used; 
unfortunately, without affecting the final result. (Forchheimer.) 

Colchicum (Meadow Saffron) is the corm and seed of the Col- 
chicum autumnale, a European plant of the nat. ord. Liliaceag. It 
contains an intensely bitter, poisonous alkaloid (colchicine, C 22 H 25 - 
N0 6 ) which by the action of acetic and mineral acids is converted 
into colchiceme and a resin; also tannic and gallic acids, resin, 
starch, sugar, etc. It is official in two forms, namely : 

Colchici Cormus (Colchicum Corm), the dried corm, about an 
inch long, white internally, grooved on one side, inodorous, taste 
sweetish, bitter and acrid. Is less active than the seed. Dose, gr. 
ij-viij [av. gr. iv]. 

Colchici Semen (Colchicum Seed), about T V i ncn thick, sub- 
globular, resembling black mustard seed but larger, very hard and 
tough, inodorous, of bitter and acrid taste. Dose, gr. j-v [av. 
gr. iij]. 

Colchicina ( Colchicine ) , a white or yellowish, amorphous pow- 
der, of saffronlike odor and bitter taste, soluble in water and in 
alcohol. Dose, gr. -j-J^ to -fa [av. gr. tJ*]. Is suitable for hypo- 
dermic injection. (Potter.) 

Collodium, Collodion, made by dissolving Pyroxylin, 4; in 
Ether, 75, and Alcohol, 25. 

Collodium Flexile (Flexible Collodion), Collodion, 92; Can- 
ada Turpentine, 5 ; Castor Oil, 3, mixed thoroughly. 

Collodium Stypticum (Styptic Collodion), Ether, 25; Alcohol, 
5 ; Tannic Acid, 20 ; Collodion to 100. 

Collodium Cantharidatum (Cantharidal Collodion, Blistering 
Collodion), Cantharides, 60; Flexible Collodion, 85; Chloroform, 
q. s. to 100. (Potter.) 
28 



416 MATERIA MEDICA 

Colocynthis, Colocynth, is the dried fruit of Citrullus Colo- 
cynthis, deprived of its rind. The plant is a native of Spain and 
Asiatic Turkey, and belongs to the nat. ord. Cucurbitaceae. The 
fruit is of the size of a small orange, white, light, spongy, inodor- 
ous, very bitter, containing many flat, brown seeds, which should 
be rejected before the pulp is used. Its active principle is Colo- 
cynthin, C 56 H 84 23 , an amorphous but crystallizable bitter gluco- 
side, readily soluble in water. It also contains Colocynthein, a 
resin, and Colocynthitin, a tasteless, crystalline powder, soluble 
in ether but not in water, and devoid of purgative action. Dose, 
gr. ss.-jss. [av. gr. j]. 

Extractum Colocynthidis {Extract of Colocynth), Dose, gr. 
J-j [av. gr. ss.]. 

Extractum Colocynthidis Compositum (Compound Extract 
of Colocynth) contains of the preceding 16 parts; Aloes, 50; Car- 
damom, 6; Resin of Scammony, 14; Soap, 14; Alcohol, 10. Dose, 
gr. v-xx [av. gr. vijss.]. 

Pilul^e Cathartics Composite (Compound Cathartic Pills) 
have of the preceding, 8 ; Calomel, 6 ; Resin of Jalap, 2 ; Gamboge, 
1J; water to make 100 pills. Dose, j-iij [av. ij pills]. (Potter.) 

Condurango. — This is the bark of Marsdenia condurango (gono- 
lobus condurango), one of the asclepiadge from Peru and Ecuador. 
It is an astringent bitter and therefore a stimulant tonic. There 
are two preparations, the fluid extract, dosage 1 to 2.5 c.c. (15 to 
40 n\ ) ; the tincture, a ten-per-cent solution, dosage 1 to 4 c.c. (15 
to 60 HI). 

Condurangin Glucoside, si. solution in water. Dose, 0.006 to 
0.015 ( T V to J gr.) t. i. d. in sweetened mixture. 

Creosotum (Creosote) is a mixture of phenols and phenol de- 
rivatives, chiefly Guaiacol and Creosol, obtained during the distil- 
lation of wood tar, preferably that derived from the beech. It 
occurs as an almost colorless, or pinkish, inflammable, oily liquid, 
of smoky odor, caustic taste, and neutral reaction ; soluble in about 
150 of water and in all proportions in absolute alcohol, ether, 
chloroform, carbon disulphid, acetic acid, and fixed and volatile 
oils. It does not coagulate albumin or collodion, though phenol 
does. It was named from its remarkable preservative power over 
meat. Much of the commercial Creosote is an impure phenol or a 
heavy oil distilled from coal tar and containing phenol and cres- 



MATERIA MEDICA 417 

ylic acid. Dose, nx j-v [av. nx iij], well diluted in wine or whisky. 
Morson's beechwood creosote is the best for internal use. (Potter.) 
Liquor Cresolis Compositus. (U. S. P.) 

Compound Solution of Cresol 

Cresol 500.0 grams. 

Linseed Oil 350.0 " 

Potassium Hydroxid 80.0 ' ' 

Water to make .1,000.0 grams. 

Cupri Sulphas (Copper Sulphate) (CuS0 4 + 5 H 2 0), blue, trans- 
lucent crystals, efflorescent, of nauseous, metallic taste and acid 
reaction, very soluble in water, soluble in 400 of alcohol. Its solu- 
tion is blue by transmitted light, green by reflected light. Dose, 
as an emetic, gr. ij-v [av. gr. iv] every ten or fifteen minutes ; as an 
astringent, gr. ^ to J [av. gr. J]. (Potter.) 

Digitalis (Fox-glove, Digitalis purpurea; Fam. Scrophulari- 
ace^e), heart tonic and diuretic. Average dose, 1 grain (0.065 
gram). The root and the leaves of the fox-glove are all used in 
making this drug. It was for some time only grown in the Black 
Forest of Germany, but it is now grown in both Europe and 
America. The caution, however, should be observed to use only 
assayed specimens, because many varieties of digitalis are prac- 
tically inert. Thus Dr. Janeway, of New York, claims that Allen's 
English leaves are the only ones that have proven successful in 
his practice. Of these leaves, the new ones of the second half year 
are four times as strong as the old ones of the first half year. 

The derivatives of digitalis are : 

Digitalin, practically insoluble in water, soluble in water and 
alcohol, almost insoluble in ether or chloroform. 

Digitoxin (C 28 H 46 O 10 ), only slightly soluble in water, spar- 
ingly soluble in ether, and readily in alcohol and chloroform. 

Digitonin, freely soluble in water; depressant (saponin) in its 
action. 

Digitalein, freely soluble in water. 

Digitin, inactive. 

Digitophyllin and Digitoflavon in the leaves. 

The solutions of the crude drug vary according to their con- 



418 MATERIA MEDICA 

tent of the several active principles. In general, alcoholic prepa- 
rations have a tendency to contain more of the digitoxin, while 
the aqueous solutions have more of the digitalin and the digitonin. 
The action of the drug may be summarized as follows (Soll- 
mann) : 

1. It increases the irritability of the cardiac muscle. 

2. It stimulates the vagus. 

3. It constricts the vessel walls, especially the arterial. 

4. It increases diuresis in cases of cardiac diseases. 

5. It stimulates and then depresses the medullary centers (pic- 
rotoxin action). 

6. It is a local irritant ; and finally, 

7. It has a veratrin action on skeletal and smooth muscle. 
Digitalis is very slowly absorbed and one cannot expect its 

action to appear in less than from twelve to twenty hours. Digi- 
toxin, however, acts much more rapidly and may show its action 
in from four to eight hours. Combined with this slow absorption 
of the crude preparations, there is a tendency to accumulative 
action. That is, the drug remains stored up in the system and 
shows no effect until many doses have been given ; then all the 
drug contained in the body gives action at once, which is some- 
times so strong as to become dangerous. *d 

While the digitalin increases the blood pressure in the splanch- 
nic area, digitoxin affects the blood pressure more nearly uni- 
formly throughout the body. 

The preparations of digitalis are : 

The Infusion. — One and one half per cent; dosage, 15 to 30 
drops (4 to 15 c.c). 

Fat-free Tincture. — Ten per cent; dosage, 20 to 30 drops 
(0.3 to 1.5). 

Digitalin, German. — Merck, powdered; dosage, to to ^ grain. 

Digitalin, French. — Merck ; dosage, -^ to -jV grain. 

Digitoxin. — Merck ; 1 milligram of the digitoxin equals 1 gram 
of the herb ; dosage, -gV of a grain. A daily dose of T V of a grain 
should not be exceeded. The ordinary dose varies from ^J-j- to T V 
of a grain. This preparation is soluble in 147 parts of water, and 
is supplied in tablets of -jJq- of a grain, but it should be remem- 
bered that it is rather expensive. 

The following note from the report of the Council on Phar- 



MATERIA MEDICA 419 

macy of the American Medical Association summarizes the present 
status of the chemistry of digitalis: 

The chemistry of digitalis is very imperfectly understood, but sev- 
eral principles have been isolated in a greater or less degree of purity. 
These include digitalin, digitalein, digitoxin, digitonin, and digitin. 
The term digitalin, unfortunately, is applied in a loose way to all of 
these principles, and in a more restricted sense to indicate digitalinum 
verum, or true digitalin, which is probably a definite substance. 

Digitalinum purum, or German digitalin, is a mixture of several 
glucosids, consisting of fifty to sixty per cent of digitonin and only 
six per cent of true digitalin. German digitalin is the preparation usu- 
ally found on the market and is ordinarily dispensed when digitalin is 
prescribed. 

French digitalin, or Homolle's digitalin, is also a mixture of several 
glucosids, but consists mainly of true digitalin. 

Merck's crystallized digitalin is neither digitalin nor digitoxin, but 
digitonin or digitin, Merck using the three terms — crystallized digitalin, 
digitonin, and digitin — as synonomous. 

Digitaline crystallisee of Nativelle is not digitalin, but is nearly 
identical with digitoxin. 

It must be remembered, therefore, that Merck's " crystallized " digi- 
talin, Merck's " pure " digitalin, and the " true " digitalin of Boehringer 
& Sons, which naturally might be supposed to be identical, are different 
in their action. (Journal A. M. A., May 8, 1909.) 

When digitalis cannot be given by the mouth it can be intro- 
duced by way of the rectum by using a tablespoonful of the in- 
fusion in four ounces of water twice daily. 

When the infusion is given by the mouth, a dose of one table- 
spoonful every two hours is not too great. 

That the dosage of digitalin has been too small is shown by 
such statements as the following: 

The growing tendency to employ digitalin in larger doses than was 
thought feasible a few years ago has prompted us to add to our list a 
\ -grain hypodermic tablet of this drug. Our assortment of hypodermic 
tablets of Digitalin, Pure (German), now includes the following grain- 
ages : ^fo, tm) -gV> iV» tV 4? and \. According to recent information 
the dose of this drug ranges from -^ to | grain. (Parke, Davis & Co.) 

Dormiol (Amylene-chloral) is the trade name of a mixture of 
equal molecules of Chloral and Amylene Hydrate, forming a col- 



420 MATERIA MEDICA 

orless, oily fluid. Dose, 3ss.-j of the ten-per-eent aqueous solution, 
in which form it is marketed. 

Dover's Powder (Pulvis Ipecacuanhce et Opii, Powder of Ipecac 
and Opium) has of Ipecac, 10; Powdered Opium, 10; Sugar of 
Milk, 80, triturated together to a fine powder. Dose, gr. iij-xv [av. 
gr. vijss.]. 

Elixirs (Elixiria), sweetened, alcoholic, agreeably flavored 
liquids, which may be simply aromatic or adjuvant, to serve as 
vehicles to disguise the taste of bitter or nauseous drugs; or they 
may contain medicinal agents. Elixir of any drug may be pre- 
pared extemporaneously from the fluid extract, e. g., Elixir 
Calumbae : 

^ Flext. calumbae gj 25.0 c.c. 

Elixir adjuvantis oiij 75.0 ' ' 

M. Sig. : Dose, one teaspoonf ul. 

The elixirs represent one of the most agreeable and promptly 
acting forms of medication, which, containing about twenty-five 
per cent alcohol by volume (with a few exceptions, viz., Elixir 
Terpini Hydratis, etc.), should, however, be employed with dis- 
crimination. 

Elixir Adjuvans (Adjuvant Elixir, Aromatic Elixir), con- 
taining twelve per cent glycerrhiza. Especially valuable to mask 
the taste of quinin. Since the active principle of the Licorice 
(Glycerrhizin) is precipitated by acids, the quinin should not be 
dissolved by the aid of dilute acid, but simply be suspended in the 
elixir as a " shake-well " mixture. 

Elixir Apii Graveolentis Compositum (N. F.), nerve stimu- 
lant and tonic. Dose, 4 c.c, or 1 fluid dram, containing 0.3 gram 
(5 grains) each of celery seed, coca, kola, and viburnum pruni- 
folium. Similar in composition to a well-known trade article. To 
avoid confusion with " Opii," the title Apii Graveolentis should 
be written out in full. 

Elixir Aromaticum (Simple Elixir), a cordial flavored with 
orange, lemon, and coriander. 

Elixir Calcii Hypophosphitis (N. F.), alterative, reconstruc- 
tive. Dose, 8 c.c. (2 fluid drams), representing 0.2 gram (4 grains) 
calcium hypophosphite. 



MATERIA MEDICA 421 

Elixir Cooe et Guaran^e (N. F.), stimulant, analgesic. Dose, 
4 c.c., or 1 fluid dram, representing 0.5 gram (7J grains) each of 
coca and guarana. 

Elixir Gentians Glycerinatum (N. F.), bitter tonic, stom- 
achic. Dose, 8 c.c, or 2 fluid drams, representing gentian, taraxa- 
cum, phosphoric acid, in glycerin and white wine, flavored with 
sweet orange peel, compound tincture cardamom, and acetic ether. 
Similar in composition to a trade article, becoming known to the 
public asa " glycerin tonic." 

Epicarin (Oxynaphthyl - Ortho - Oxytoluic Acid; C 6 H 3 (OH) 
(COOH) (Ch 2 C 10 H 6 OH) 2: 3: 1 = C 18 H 14 OJ. Epicarin is /?- 
naphthol-hydroxy-toluic acid. It forms colorless or yellowish 
needles, melting at 190° to 195° C. (380° to 389° F.), diffi- 
cultly soluble in water, but easily soluble in alcohol, ether, 
acetone, and in soaps. It dissolves in oils on addition of a 
little ether. It has the character of a strong acid, forming 
well crystallized salts, which, however, are sparingly soluble in 
water, particularly the sodium salt. On exposure to air it ac- 
quires a reddish color, due to oxidation; if it is then recrystal- 
lized from glacial acetic acid, colorless crystals are again obtained, 
which melt at 166° C. (338° P.). These, however, retain a little 
acetic acid, but lose this by heating at 120° C. (248° F.). 

Being a strong acid, it is incompatible with alkaline hydroxids 
or carbonate, especially those of sodium, with which it forms an 
almost insoluble salt. It should not be exposed to The air, which 
colors it red. 

Epicarin is a nonpoisonous antiseptic and parasiticide. Ad- 
ministered internally, it is excreted mostly undecomposed. It is 
said to be useful in the treatment of skin diseases, particularly 
scabies, tinea tonsurans, prurigo, and certain forms of eczema. 

Dose : It is used only externally in the form of a five- to twenty- 
per-cent ointment, with petrolatum or wool fat (lanolin) as base, 
or in the form of oily or alcoholic solutions (ten per cent). (N. 
N. R.) 

Epinephrin, a principle isolated by Abel, is found only in the 
medulla of the suprarenal gland, and in very small quantity, but 
it is very active, the t^stt of a grain per kilo of body weight pro- 
ducing a distinct effect on the blood pressure. Takamine has iso- 
lated another principle, named 



422 MATERIA MEDICA 

Adrenalin, which is said to manifest all the properties of the 
gland substance in greater concentration, being the most powerful 
hemostatic and astringent known, and a cardiac stimulant of great 
energy. It is claimed to be 600 to 1,000 times more powerful than 
the extract, the rowoir °^ a gram ( 1 3 j, 00 of a grain), administered 
intravenously, producing a distinct effect upon the adult man ; and 
the fraction of a drop of a solution of 1 in 10,000 blanching the 
normal conjunctiva within thirty to sixty seconds. Its intravenous 
administration acts powerfully on the muscular system, especially 
the muscle of the heart and blood vessels, causing an enormous 
rise of blood pressure. It is nonirritant, nontoxic, noncumulative, 
devoid of injurious properties, and has little or no effect upon the 
cerebrum. It has no anesthetic power in itself, but when used in 
connection with cocain, holocain, etc., it prolongs the duration of 
the anesthesia produced by them. (Potter.) 

Ergot. 

Our experiments would lead us thus to advise the use of ergot in 
certain emergencies, namely, in shock and in postpartum hemorrhage. 
In both these cases we should use the drug intravenously, but in both 
cases the effect should be carefully watched and care taken not to re- 
peat the dose too frequently. 

Summary. — That most galenical preparations of ergot contain con- 
siderable amounts of the active principles but do not show any great 
or marked action when given per os. Their usually recommended doses 
are much too small. 

That ergotin is a highly active alkaloid and has the properties of 
ergot most desirable to medicine. 

That ergotin brings about a long-enduring contraction of the walls 
of arterioles, and increases the movements of the uterus. 

That this action is feeble when ergotin is given per os, but more 
marked in subcutaneous injections and much more marked when given 
intravenously. 

That in cases where a rapid and certain action is wished, either in 
shock or in postpartum hemorrhage, we would recommend intravenous 
administration. We would recommend further, if the effect proved too 
evanescent to achieve the results desired, that suprarenal be adminis- 
tered subsequently in repeated small doses. (Cronyn and Henderson.) 

Ether {2Ether [U. S. P.], Sulphuric Ether, Ethyl Oxid) con- 
tains ninety-six per cent by weight of (C 2 H 5 ) 2 ; made by acting on 



MATERIA MEDICA 423 

alcohol with strong sulphuric acid, distilling and purifying 
the product. End reaction = 2C 2 H 5 OH + H 2 S0 4 + (C 2 H 5 ) 2 + 
H 2 + H 2 S0 4 . Sp. Gr. 0.716 to 0.717; boils at 35.5° C. Inflam- 
mable. Soluble in 10 volumes of water, all proportions of alcohol, 
etc. Dose, 1 c.c. = 15 TT\,, U. S. P. 

This is the ^Ether Purificatus (B. P.). JEther (B. P.) is a less 
pure and more watery ether. 

The preparations of Ether are : 

Spiritus iETHERis (J Ether, § Alcohol, U. S. P. ; ^ Ether, T 9 ¥ 
Alcohol, B. P.). Dose, 1 to 4 c.c. (J to 1 dram) (4 c.c. = 1 dram, 
U. S. P.). 

Spiritus ^Etheris Compositus (U. S. P., B. P.). " Hoffman's 
anodyne/' Above with 2.5 per cent of " Ethereal oil." Dose, 
same. 

JEther Aceticus (U. S. P., B. P.; C 2 H 5 .C 2 H 3 2 ). Boiling 
point, 72° C. Soluble in 7 parts water, freely in alcohol, etc. 
Dose, 1 c.c. = 15 TTl, U. S. P. 

JEthylis Chloridum (U. S. P.; Ethyl Chlorid; C 2 H 5 C1). Pre- 
pared by the action of HC1 on absolute alcohol. Colorless, ex- 
tremely volatile liquid, of sharp, sweet taste and peculiar odor. 
Inflammable. Sp. Gr. 0.918 at 8° C. Boiling point, 12.5° to 
13° C. Sparingly soluble in water, readily in alcohol or ether. 
Dispensed in special glass or metal tubes. Used for freezing and 
for general anesthesia. 

Eucain (Beta-Eucain Hydrochlorid, Beta-Eucaince Hydro- 
chloridum, Eucain Hydrochlorid- ft) . — Beta-eucain hydrochlorid, 
C 5 H 7 N(CH 3 ) 3 (C 6 H 5 COO).HCL, is the hydrochlorid of 2, 6, 6- 
trimethyl-4-benzoyl-hydroxypiperidin. 

It is prepared by treating diacetonamin with paraldehyd, re- 
ducing the product with metallic sodium, benzoylating the vinyl- 
diacetonalkamin (melting at 138° C.) so produced by treatment 
with benzoylchlorid, neutralizing the resulting benzoylvinyldiace- 
tonalkamin with hydrochloric acid and crystallizing. 

It forms a white crystalline powder, soluble in 20 to 30 parts 
of water at the ordinary temperature, but more soluble in warm 
water, soluble in 25 to 30 parts of alcohol, producing neutral solu- 
tions which can be sterilized by boiling without change. The aque- 
ous solutions yield either soluble precipitates of the free base on 
addition of alkali hydroxids or carbonates. 



424 MATERIA MEDICA 

Beta-eucain hydrochlorid is a local anesthetic like cocain, but 
weaker and devoid of the stimulating properties of the latter. It 
does not dilate the pupil, nor does it contract the blood vessels as 
does cocain. It has the advantage of stability even on prolonged 
boiling. It may be used in all cases in which cocain is indicated 
as a local anesthetic, especially in ophthalmology. 

Dose : It may be applied in a two- to three-per-cent solution to 
the eye, five to ten per cent for the nose, and five to ten per cent 
for ointment for hemorrhoids. (" New and Nonofncial Remedies 
of the A.M. A.") 

Eucalyptus (U. S. P.). — The leaves of Eucalyptus globulus, 
Myrtaceas. Australia; cultivated. Contains a resin, volatile oil, 
etc. The preparations are : 

Fluidextractum Eucalypti (U. S. P.). — Three fourths alco- 
hol. Dose, 2 c.c. = 30 Tl\. Becomes turbid with water. 

Elixir Eucalypti (N. F.). — 1:8. Dose, 8 to 15 c.c. (2 to 
4 drams). 

The above Eucalyptus preparations are used mainly when the 
local (carminative) effect on the intestine is desired. 

Oleum Eucalypti (U. S. P., B. P.). — The volatile oil. Dose, 
0.3 to 20 c.c. (5 to 30 ITt) (0.5 c.c. = 8 m., U. S. P.) ; or for in- 
halation. 

Eucalyptol (U. S. P.) (Cineol; C 10 H 18 O) constitutes fifty per 
cent of the oil. Colorless liquid. Dose, 0.3 c.c. = 5 nt. 

Eucalyptus oil is an active disinfectant as well as a local 
irritant. 

Fibrolysin. — Fibrolysin is a sterilized solution of a double salt 
of thiosinamin and sodium salicylate (NHCS.NHCHCH: CH) 
CH(OH) (COONa), containing fifteen per cent of the double salt. 
It is prepared by mixing the two compounds in solution. 

It is an aqueous, odorless solution. It does not keep well in 
the air, but is marketed in sealed, brown glass vials, each contain- 
ing 2.3 c.c, 37 TTL of the solution equivalent to 0.2 gram (3 grains) 
of thiosinamin. 

The tests are those of thiosinamin and sodium salicylate. 

Those of thiosinamin, with the advantage of quicker absorp- 
tion and freedom from pain or irritation, on account of its solu- 
bility and aqueous vehicle. 



MATERIA MEDICA 425 

Dose: The contents of one vial (2.3 c.c. = 0.2 gram thiosina- 
min) by subcutaneous, intramuscular, or intravenous injection, 
one injection being administered daily or every second or third 
day. (N.N. R.) 

Formaldehyd (HCHO) is a colorless, irritant gas, discovered by 
von Hoffman in 1868, and prepared by the oxidation of methyl 
alcohol. It is freely soluble in water, and is found on the market 
in the form of a forty-per-cent solution (Formalin). The solu- 
tions tend to become inactive by the formation of the insoluble, 
polymeric paraform. This conversion is now prevented by 
chemic means. 

Formaldehyd in solution inhibits the growth of bacteria when 
it is present in the proportion of 1 : 5,000 to 1 : 20,000, according 
to the species. It checks the growth in 1 : 30,000 ; stronger solution 
(one half to two and one half per cent, according to the species 
and to the time of exposure) kill all bacteria and spores. The 
gas is similarly antiseptic, especially when it is moist. Formal- 
dehyd surpasses most other disinfectants in penetrating power, 
and does not injure metals or fabrics. It is employed for disin- 
fections of rooms, etc., as the gas prepared by spraying the solu- 
tion, by suspending sheets saturated in the solution, or best by the 
volatilization of paraform; for instruments and other articles, it 
is used as one-half- to one and one-half -per-cent solution ; feces are 
deodorized immediately by a one-per-cent solution, and rendered 
germ-free in ten minutes. The propriety of its internal use may 
be doubted on account of its irritant qualities, but it has been em- 
ployed for the disinfection of hands (one per cent), as a mouth 
wash and gargle (one half per cent), in skin diseases and hyperi- 
drosis (2.5 per cent), for painting the throat in diphtheria or 
tonsillitis (two and one half to five per cent), and as a preservative 
for milk and other foods and beverages (1:20,000 to 1:30,000). 
The evaporation of a small amount of the solution in the room 
has also been recommended in tuberculosis. 

Gelsemmm (U. S. P.) (Gelsemii Radix, B. P.; Yellow Jasmine). 
— Rhizome and roots of Gelsemium sempervirens, Loganiascege. 
Southern United States. 

Fluidextractum Gelsemii (U. S. P.). — Alcohol. Dose, 0.05 
c.c. = 1 TTi. 



426 



MATERIA MEDICA 



Tinctura GrELSEMU (U. S. P., B. P.).— Ten per cent; f alcohol. 
Dose, 0.5 c.c. = 8 nx. 

Gelseminin, the active alkaloid of gelsemium, produces effects 
in general almost identical with those of coniin. Its depressing 
action on the central nervous system is more marked than that 
of the latter, so that the central paralysis precedes the peripheral 
even in frogs. 

It has a very decided mydriatic effect upon the pupil, especially 
on local application. This is believed by some to be due to paraly- 
sis of the oculomotor endings after the manner of atropin, but the 
question cannot be considered as definitely settled. The mydriasis 
lasts from twelve to seventeen hours. 

Gelseminin, C 22 H 26 N 2 3 . Dose, 0.0005 to 0.002. (Sollmann.) 

Tincture Gentian Compound (Tinctura Gentianm Composita), 10 
grams Gentian with bitter orange peel and cardamon, in 100 c.c. 
of the mixture. Bitter tonic, stomachic. Average dose, 1 fluid 
dram (4 c.c). 

Of the gentian lutea the root is used. The plant is a native of 
Switzerland. It has preserved for decades a reputation as a 
stomachic bitter. 

Guaiacol (C 7 H 8 2 ) is one of the chief constituents of creosote, 
and is prepared synthetically from catechol. It occurs as a color- 
less solid or liquid, of agreeable and aromatic odor, soluble in al- 
cohol, ether, acetic acid, and glycerin. Dose, TT\ v-xv [av. TTtviij] 
in capsule, pill, or whisky. 

Guaiacolis Carbonas (Guaiacol Carbonate, Duotal) occurs as 
an almost tasteless and odorless, white, crystalline powder, insoluble 
in water. Dose, gr. v-xx or more [av. gr. xv], gradually increased 
to a maximum of 3jss. per diem. 



Hexamethylenamin. — Hexamethylenamin liberates formaldehyd 
in the kidneys. It is obtained by the action of ammonia on formal- 
dehyd. It is soluble in 1J parts of water and 10 parts of alcohol. 
It dissolves uric-acid crystals and urates. Its urate-dissolving 
power is inferior to that of piperazin. Its dosage varies from 0.2 
to 1 gram (3 to 15 grains) in water. (See Journal of the Amer- 
ican Medical Association, vol. li, No. 10; September 5, 1908, p. 818.) 

Hydrastis (Golden Seal, Yellow Puccoon, Yellow Root, Orange 
Root), dried rhizome and roots of hydrastis canadensis (Fam. 



MATERIA MEDICA 427 

Ranunculacese). Average dose, 30 grains (2 grams). (See the 
Journal of the American Medical Association for July 4, 1908.) 

The active principles are said to be hydrastin, two and one half 
per cent; berberin, three and one fourth per cent; canadin, in 
traces. Canadin has a morphin-like action, but, inasmuch as it is 
so small in quantity, it does not cause any material effects in the 
use of the crude drug. 

Berberin is a bitter tonic. Large doses give a falling blood 
pressure from a vasomotor paralysis. It is a yellow drug and will 
stain the clothing if brought in contact with it. 

Hydrastin has a narcotin-like action. (See Opium.) The for- 
mer yields hydrastinin by oxidation, the latter cotarnin. Moderate 
doses of hydrastin have a strychnin effect on the cord. It has a 
weak local anesthetic action. Small doses cause a rise in the blood 
pressure, varying according to the condition of the drug. Hydras- 
tin is insoluble in water, but soluble in 135 parts of alcohol. The 
dose varies from 0.01 to 0.03 (J to -J grain). 

Hydrastintn (Hydrastince Hydrochloridum) . — It is usually 
produced by oxidizing the hydrastin with nitric acid. Light yel- 
lowish needles of microcrystalline powder, odorless and very bit- 
ter. Very soluble in water or alcohol, in 286 parts chloroform, 1,300 
ether. 

Hydrastinin has no spinal action or paralysis of the muscle as 
hydrastin does. On the other hand, it stimulates the cardiac and 
arterial muscle. (This stimulation, as in the case of other drugs, 
if pressed too far, leads to a final paralysis.) It increases the 
blood pressure. It is usually given in the form of the hydrochlorid 
in the dose of 3 centigrams (0.03). 

Hydrogen Peroxid, a slightly acid, aqueous solution of Hydrogen 
Dioxid (H 2 2 = 33.76), which should contain, when freshly pre- 
pared, about three per cent, by weight, of absolute Hydrogen 
Dioxid, corresponding to about 10 volumes of available oxygen. 
It should be kept in a cool place. Upon removing the stopper 
from the bottle not more than a slight pressure should be observed. 

A colorless liquid, without odor, slightly acidulous to the taste, 
and producing a peculiar sensation and soapy froth in the mouth ; 
liable to deteriorate upon keeping or protracted agitation. If the 
stopper in the bottle be replaced by a pledget of cotton, deteriora- 
tion is retarded. 



428 MATERIA MEDICA 

When exposed to the air at the ordinary temperature, or when 
heated on a water bath at a temperature not exceeding 60° C. 
(140° F.), the solution loses chiefly water. When rapidly heated, 
it frequently decomposes suddenly. 

Hyoscin Hydrobromid (C 17 H 21 N0 4 .HBr + 3H 2 = 434.92; Hy- 
oscinse Hydrobromas, Pharm., 1890). — The hydrobromid (HBr.- 
C 17 H 21 N0 4 -f 3H 2 0) of an alkaloid, chemically identical with scopo- 
lamin, obtained from hyoscyamus and other plants of the Solanaceae. 
It should be kept in well-stoppered, amber-colored vials. (U. S. P.) 

Hyoscyamus. — The preparations are: 

Tinctura Hyoscyami — Dose, 0.5 to 1.5 c.c. (8 to 25 ™j. 

Fluidextractum Hyoscyami — 0.15 to 0.3 c.c. (2J to 5 trt). 

Extractum Hyoscyami — 0.05 to 0.1 gram (f to 1^ grains). 

Ichthyol (Ammonii Ichthyosalphonas, Ammonium Sulpho-Ich- 
thyolate, Ammonium Ichthyol Sulphonate, Ammonium-Ichthyol) . — 
Ichthyol consists largely of the ammonium salts of sulphonic acids 
derived from the tar of a bituminous shale which is found in the 
Tyrol and which contains the remains of many fossil fishes. The 
exact composition and nature of ichthyol is still doubtful. 

It is incompatible with acid and saline solutions, fixed alkalies, 
their carbonates and iodids, alkaloidal salts, mercuric chlorid, etc. 

Iodids. — It should be remembered that the iodids have a posi- 
tive ionic action separate from that of the crude drug. This 
action may be analyzed as follows: (1) It increases the catabolism 
and thereby the absorption of pathological formations. (2) It 
has a specific action analogous to the above in tertiary syphilis 
and its sequela?. (3) This increase of catabolism makes the drug 
extremely useful in such conditions as chronic rheumatism and 
asthma, where there is an accumulation of pathological deposits. 
In short, the real effect of the iodids may be summarized under 
the term " increase of catabolism," because pathological material 
is more easily broken down than normal; hence in using such a 
drug as the iodids, this material is broken down and absorbed 
before the normal tissues are touched. Its effect is directly on the 
cells and not on the circulation. 

The excretion is by way of the kidneys and begins in ten to 
fifteen minutes after absorption. It reaches its maximum in two 
hours. The giving of the chlorids and nitrites hastens excretion. 



MATERIA MEDICA 429 

Iodism is possibly due to the irritative effect of the ion while 
being excreted through the skin and elsewhere. It is usually pre- 
vented by giving plenty of alkalies. 

The drug is used in tertiary syphilis, in chronic rheumatism, 
in asthma for the absorption of hyperplastic tissue, in combination 
with expectorants in order to increase the secretion in the mucous 
membrane of the bronchial tubes. Since the potassium ion has a 
similar effect to the iodid ion, the use of potassium iodid gives a 
maximum effect in the way of catabolism. The drug is usually 
counted incompatible with quinin and strychnin. A very efficient 
form of the drug is the nascent iodid given in the form of the 
dilute hydriodic acid (ten per cent), the dose of which is 0.5 c.c. 
(6 to 8 drops). The syrup of hydriodic acid, a one-per-cent solu- 
tion, is especially agreeable in dealing with children. It should 
be given one half hour before meals in doses of one teaspoonful. 

Iodoform possesses not only the iodid action, but also an action 
of its own. This latter action produces delirium and mania when 
the drug is given in too great doses. The temperature rises, the 
pulse rate is increased ; hence, in using iodoform as a dusting pow- 
der or for vaginal or rectal packs, one should guard against suf- 
ficient absorption to produce this intoxication. Some of the 
iodoform is broken up into iodids; some is excreted unchanged. 
The presence of the drug on exposed tissue causes granulation on 
account of its irritation. Iodoform as such has little antiseptic 
action ; it is antiseptic only as it is broken up by the action of 
ferments of other reagents into nascent iodin. This occurs so 
slowly that the effects are mild, but quite sufficient to be markedly 
antiseptic to bacteria and stimulant to the cells. Iodoform is 
therefore very valuable in treating open wounds, since it promotes 
healing by stimulating granulation and lessening or preventing in- 
fection. It is the most universally used dusting powder ; it is also 
injected into tubercular joints, usually as an emulsion with glycerin. 

Iodoform has, however, a number of disadvantages. The most 
objectionable feature is the persistent odor, which cannot be dis- 
guised by any perfume. Iodoform is also apt to develop irritant 
phenomena in susceptible individuals, producing particularly ec- 
zemas, even in minute amounts. 

Ipecacuanha (U. S. P., B. P.). — The root of Cephselis Ipeca- 
cuanha Rubiaceae. Brazil and Colombia; cultivated in India. 



430 MATERIA MEDICA 

Two varieties are found on the market, called Rio and Car- 
thagena Ipecac. The B. P. recognizes only the former, the U. S. P. 
both. Recent researches have shown that the Carthagena variety 
contains more of both alkaloids, but particularly of cephalin, and 
is therefore the more valuable. 

Besides the active ingredients enumerated, there are starch, 
volatile oil, etc. The total alkaloids amount to 2.7 per cent to 2.9 
per cent (at least 2 per cent U. S. P.). The ratio of emetin to 
cephalin varies from 3 emetin: 1 cephalin in Rio to |: 1 in 
Carthagena. 

Pulvis Ipecacuanha. — Dose, as emetic, 1 to 2 grams (-J to J 
teaspoonful) in lukewarm water (U. S. P.: Expectorant, 0.065 
gram = 1 grain; emetic, 1 gram = 15 grains). 

The simple preparations are : 

Fluidextractum Ipecacuanha (U. S. P.). — | alcohol 1.75 per 
cent alkaloids. Dose, Expectorant, 0.05 to 0.3 c.c. (1 to 5 n\); 
emetic, 2 c.c. (30 TTl). (U. S. P.: 0.05 c.c. = 1 1U ; 1 c.c. = 15 ttl.) 

Extr. Ipecac Liq. (B. P.). — Alcohol; 2.25 per cent alkali. 
Dose, as the preceding. 

Syrupus Ipec. (U. S. P.). — Seven per cent of fldext. ; contains 
acetic acid. Dose, as expectorant, 1 c.c. = 15 Til ; as emetic, 15 c.c. 
= 4 ounces (U. S. P.). 

Vinum Ipec. (U. S. P.). — Ten per cent of fldext. Dose, as ex- 
pectorant, 0.5 to 2 c.c. (10 to 30 TTt, U. S. P.) ; as emetic, 15 c.c. 
(4 ounces). 

Vinum Ipec. (B. P.). — Five per cent; 0.1 per cent alkaloids. 
Dose, twice the preceding. 

Acetum Ipecacuanha (B. P.). — As the wine. 

The compound preparations are: 

Pulvis Ipecacuanha et Opii (U. S. P.; Pulvis Ipec. Compos., 
B. P.). — Dover's powder: ten per cent of each active ingredient. 
Dose, 0.05 to 1 gram (1 to 15 grains). (0.5 gram = 1\ grains, 
U. S. P.) 

Trochisci Morphina et Ipecacuanha (B. P.). — Each contains 
¥ V grain (0.0016 gram) of morphin hydrochlorate and T V grain 
(0.005 gram) ipecac. 

Tinctura Ipecacuanha et Opii (U. S. P.) contains ten per 
cent of each. Dose, 0.2 to 1.2 c.c. (3 to 20 ra). (0.5 c.c. = 8 ra, 
U. S. P.) 



MATERIA MEDICA 431 

Iron. — It should be remembered that iron is a natural part of 
the human body, therefore the giving of it in cases of deficiency 
is merely feeding the body needed food. This remark is par- 
ticularly applicable in the case of young women from puberty 
through adolescence, because at this time there seems to be a need 
of additional iron to the female organism. 

The metal is locally astringent, producing this effect by the 
precipitation of the proteids. This astringent action renders the 
metal antiseptic also. It should be remembered that iron may 
produce fatal corrosive poisoning from the intestinal tract. 

The iron action produces gastrointestinal irritation, diarrhea, 
and finally paralysis of the central nervous system. 

The salts of iron are absorbed chiefly in the duodenum and 
jejunum, the inorganic salt being absorbed just as well as the 
organic, but is changed in the mucosa to an organic salt. Most of 
the iron salts are excreted by the colon. 

Blaud's Mass (Pilula Ferri Carbonatis). — The formula is: 

Ferrous sulphate 16 

Potassium carbonate 8 

Sugar 4 

Tragacanth 1 

Althaea 1 

Glycerin and water in sufficient quantity to make 100 parts. 

Saccharated Ferrous Carbonate (Ferri Carbonas Saccha- 
rahis; FeC0 3 ). — Greenish-brown powder, odorless or sweetish, 
then slightly ferruginous taste. Partially soluble in water. Cha- 
lybeate tonic. Average dose, 4 grains. It should be kept well 
stoppered, as it gradually becomes oxidized in contact with air. 

It may be used instead of Blaud's mass and will probably be 
just as efficient. This may be given in a gelatin capsule, and is 
used in the same dosage as Blaud's mass. 

Ovoferrin (Ferri Vitellinam Syntheticum) . — Ovoferrin is a 
solution containing five per cent of an artificial proteid product in 
which iron is present in the so-called " organic " or " masked ,: 
form (a form which does not give the iron test directly). The 
solution also contains ten per cent of alcohol and some aromatics. 

Ovoferrin is prepared by modifying serum-albumin by elec- 
trolysis, producing a proteid which is classed by the manufacturers 
29 



432 MATERIA MEDICA 

as a vitellin, and introducing ferric hydrate into this proteid by 
heating under pressure. The ' ' vitellin ' ' constituent of this prepa- 
ration should not be confounded with the well-known vitellin of 
the yolk of eggs. 

The solution has a reddish-brown color, little odor, and a flat, 
slightly aromatic and alcoholic taste. 

The solution does not give a blue color on the addition of potas- 
sium f errocyanid solution ; a blue tint develops slowly if an equal 
volume of five-per-cent hydrochloric acid is added to the mixture ; 
a deep-blue color develops at once if this mixture is boiled (dif- 
ferent from egg yolk). 

The solution is not precipitated by boiling, but gives precipi- 
tates with the alkalies, with which it is incompatible. It is also 
precipitated by acids. 

Ovoferrin is not appreciably affected by the gastric juice, as 
0.5-per-cent solution of hydrochloric acid liberating its iron very 
slowly and incompletely. The product ranks with the other forms 
of artificially masked iron, which are devoid of the local action of 
the soluble inorganic iron salts, and, according to some authorities, 
are more readily absorbed and utilized. 

Dose: 8 to 16 c.c. (2 to 4 fluid drams) corresponding to 0.03 to 
0.06 gram (J to 1 grain) three times a day. (N. N. R.) 

Kaolinum (Kaolin) is a native aluminum silicate, powdered 
and freed from gritty particles by elutriation. It is a fine white 
clay, derived from the decomposition of the feldspar of granitic 
rocks. It is used as an excipient for the easily reduced metallic 
salts, and as an ingredient of 

Cataplasma Kaolini (Cataplasm of Kaolin) contains Kaolin, 
Glycerin, Boric Acid, Thymol, Methyl Salicylate, Oil of Pepper- 
mint. It is identical with the trade preparation known as Anti- 
phlogistic (U. S. P.) 

Acidum Lacticum (Lactic Acid), a liquid organic acid, composed 
of not less than seventy-five per cent, by weight, of absolute lactic 
acid (CH3CHOH.COOH = 89.37) and about twenty-five per cent 
of water. 

Specific gravity, about 1.206 at 25° C. (77° F.). 

Freely miscible with water, alcohol, or ether; insoluble in 
chloroform, petroleum benzine, or carbon disulphid. (U. S. P.) 



MATERIA MEDICA 433 

Lysol. — Lysol is a preparation made by dissolving in fat and 
saponifying with alcohol that part of tar oil which boils between 
190° and 200° C, and is a brownish, clear, oily fluid, smelling 
somewhat like creosote. It is used for the same antiseptic purposes 
as creolin, but possesses the advantage of forming a clear, soapy 
fluid when mixed with water, in which instruments can be seen. 

Mercury. — Hydrargyrum cum Creta (Mercury with Chalk, 
Gray Powder) has of Mercury, 38; Honey, 10; Prepared Chalk, 
57 ; Water, q. s., shaken, triturated together, dried to 100, and then 
reduced to a uniform gray powder. Dose, gr. ss.-x [av. gr. iv]. 

Massa Hydrargyri (Mass of Mercury, Blue Mass, Blue Pill) 
has of Mercury, 33 ; Licorice, 10 ; Althsea, 15 ; Glycerin, 9 ; Honey 
of Rose, 33. Each grain contains gr. J of Mercury. Dose, gr. ss. 
-x [av. gr. iv]. 

Unguentum Hydrargyri (Mercurial Ointment). — Mercury, 
50 ; Lard, 25 ; Suet, 23 ; Oleate of Mercury, 2, triturated together, 
until globules of Mercury cease to be visible under a lens having a 
magnifying power of ten diameters. 

Unguentum Hydrargyri Dilutum (Blue Ointment) has of the 
preceding, 67, with Petrolatum, 33, thoroughly mixed. 

Hydrargyri Chloridum Corrosivum (Corrosive Mercuric 
Chlorid, Bichlorid of Mercury, Corrosive Sublimate; HgCl 2 ), 
heavy, colorless crystals, of acrid, metallic taste and .acid reaction ; 
soluble in 16 of water and in 3 of alcohol, in 2 of boiling water, 
1.2 of boiling alcohol, 4 of ether, and in about 14 of glycerin. 
Dose, gr. ^Vro [av. gr. *V] • 

Hydrargyri Chloridum Mite (Mild Mercurous Chlorid, Sub- 
chlorid of Mercury, Calomel; HgCl), a heavy, white, impalpable 
powder, odorless and tasteless; insoluble in water, alcohol, or 
ether; is an ingredient of Pil. Catharticas Co. Dose, gr. -gV-gr. v. 
The dose depends on the effect desired. [Av. laxative, gr. i j ; al- 
terative, gr. j.] 

Hydrargyrum Ammoniatum (Ammoniated Mercury, White 
Precipitate, Mercuric Ammonium Chlorid; HgNH 2 Cl) is a white, 
insoluble powder, odorless and tasteless. Used only externally. 

Unguentum Hydrargyri Ammoniati. — Ointment of Ammoni- 
ated Mercury (White Precipitate Ointment) : Ammoniated Mer- 
cury, 10; White Petrolatum, 50; Hydrous Wool Fat, 40. 



434 MATERIA MEDICA 

Hydrargyri Oxidum Flavum (Yellow Mercuric Oxid; HgO), 
an orange-yellow, heavy, impalpable powder, odorless and tasteless, 
insoluble in water or alcohol, but wholly soluble in nitric or hydro- 
chloric acid. Used to prepare : 

Unguentum Hydrargyri Oxidi Plavi (Ointment of Yellow 
Mercuric Oxid), strength, 1 to 9. 

Hydrargyri Oxidum Rubrum (Red Mercuric Oxid, Bed Pre- 
cipitate; HgO), a heavy, orange-red, crystalline powder, having 
the same properties as the yellow oxid, from which it differs only 
in being crystalline and in a less minute state of subdivision. Dose, 

gr. tWV 

Lotio Hydrargyri Nigra (Black Wash, Unofficial), prepared 
by adding Calomel, gr. xxx, to Lime Water, §x, producing the 
black oxid. 

Hydrargyri Iodidum Flavum (Yellow Mercurous Iodid, Pro- 
tiodid of Mercury; Hgl), a dull green or greenish-yellow powder, 
insoluble in alcohol or ether and almost so in water. Dose, gr, T V 
-J [av. gr. i]. 

Unguentum Hydrargyri Nitratis (Ointment of Mercuric Ni- 
trate, Citrin Ointment). — Mercury, 7, dissolved in Nitric Acid, 
17J, adding Lard, 76. 

Methylioninae Hydrochloridum (U. S. P., Methylene Blue — medic- 
inal — not to be confused with methyl blue, C 16 H 18 N 3 SC1), readily 
soluble in water or alcohol. Dose, 0.02 to 0.25 gram (-§ to 4 grains). 
(0.25 gram = 4 grains, U. S. P. Externally, in 0.5-per-cent solu- 
tion for mucous membranes ; in two per cent for skin. 

The drug has been used considerably as analgesic and antipy- 
retic in neuralgia, neuritis, and sciatica; as an antipyretic in 
cystitis, urethritis, conjunctivitis, and in skin diseases; as an anti- 
zymotic in malaria. It paralyzes the malarial plasmodia even more 
powerfully than does quinin, but in practice it has not proven a 
very useful substitute for the alkaloid. It sometimes produces 
gastrointestinal irritation, vesical spasm, and excessive diuresis. 
It is sometimes used as a diuretic. 

Beta-Naphthol (U. S. P.; Naphthol, B. P.). — A monatomic 
phenol occurring in coal tar, but usually prepared from naphtha- 
lene. It should be kept in dark, amber-colored, well-stoppered bot- 
tles. It occurs as a colorless or pale, buff-colored, shining crys- 



MATERIA MEDICA 435 

talline laminae or as a white or yellowish-white crystalline powder, 
having a faint phenol-like odor and a sharp and pungent but not 
persistent taste. It is permanent in the air. It is soluble in about 
950 parts of water and in 0.61 parts of alcohol at 25° C. (77° F.) ; 
in about 75 parts of boiling water, and very soluble in boiling al- 
cohol; easily soluble in ether, chloroform, or a solution of alkali 
hydroxids. Dose, 2 to 5 grains. (See Epicarin.) 

Nitrites. 1 — The group action of the nitrites is the dilation of 
the superficial blood vessels, with a blushing of the face and neck ; 
later, a dilation of the internal blood vessels and a fall of the blood 
pressure. Large doses paralyze the central nervous system in the 
same order as does ether (narcotic effect). There is a final depres- 
sion of the heart muscle and the formation of methemoglobin. 
(Tyrode.) 

Sollmann analyzes the action of this group as follows: 

1. Paralysis of the vaso-constrictor mechanism, mainly pe- 
ripheral. 

2. Paralysis of the vagus center. 

3. Slow paralysis of muscles, of all kinds with which it comes 
in contact. 

4. Methemoglobin formation. 

In using the nitrites, it should be remembered that the dilation 
of the blood vessels is especially pronounced in those of the 
meninges, and that therefore there is a tendency to headache and 
even syncope. 

The elapse of time before the various nitrites show their effect 
is as follows: 

1. Nitroglycerin, 1 minute. 

2. Sodium and potassium nitrites, 5 minutes. 

3. Erythrolnitrate, about 5J minutes. 

4. Manitol nitrate, about 12 minutes. 

The amount of fall pressure in millimeters of mercury was 
found to be (by Matthew) : 

1. Nitroglycerin, 28 millimeters. 

2. Sodium and potassium nitrites, 32 millimeters. 

1 A valuable article on the use of the vaso-dilators in high blood pressure is to 
be found in the Quarterly Journal of Medicine for April, 1909, by Edwin Matthew, 
from which many of the following statements have been obtained. 






436 MATERIA MEDICA 

3. Erythrolnitrate, 35 millimeters. 

4. Manitol nitrate, 35 millimeters. 

This is the average fall. The difference between the greatest 
and the least does not exceed six millimeters. 

The time in which the maximum fall was reached was as 
follows : 

1. Nitroglycerin, 4| minutes. 

2. Sodium and potassium nitrites, 14 minutes. 

3. Erythrol tetranitrate, 22 minutes. 

4. Manitol hexanitrate, about 100 minutes. 

These nitrites begin to act in 1, 5, 5J, and 10 minutes respec- 
tively. The maximum, therefore, is produced in 3J, 9, 16J, and 90 
minutes after the vaso-dilator action begins. The amount of fall 
produced by each is about the same, and therefore with the spirit 
of glyceryl trinitrate there is a very sudden and prompt action. 
The action is not so sudden in the case of sodium and potassium 
nitrites, more prolonged with erythrol nitrate, and, lastly, a very 
gradual and slow action with manitol nitrate. 

The rise in pressure after the fall: 

1. With the spirit of glyceryl trinitrate, the pressure begins to 
rise almost immediately after the maximum fall has been reached. 
The rise is slower than the fall, but in all cases the effect of the 
drugs has completely passed off in thirty minutes. 

2. Sodium and potassium nitrite maintain their action from 
forty to fifty minutes. The rise is then slow and the effect does 
not pass off until two hours have passed since the administration. 

3. Erythrol and manitol behave alike as regards length of ac- 
tion. The maximum effect is maintained for between one and two 
hours. The rise is very gradual, and the original level is reached 
only after five or six hours from the time of administration. 

Matthew found that in the case of Bright 's disease a stage is 
reached when the nitrites produce little or no response, although 
they seem to be effective in the earlier stages. When marked edema 
is present in the case of heart or kidney disease, the nitrites do not 
act well until after the edema has disappeared, then the usual vaso- 
dilator action may reappear. 

For therapeutic purposes, a fall of 30 millimeters of mercury 
is sufficient for all practical purposes. The dose of the liquor tri- 
nitrini (equivalent to the spirit of glyceryl trinitrate) is 2 milli- 



MATERIA MEDICA 437 

grams (-^ grain), the dose to be repeated within a half hour if 
necessary. With sodium and potassium nitrites, it is necessary 
to give 2 grains (0.13). The dose may be repeated after two 
hours. Erythrolnitrate produces an effect with J to 1 grain which 
lasts for six hours. Inasmuch as this drug sometimes produces 
unpleasant sensations, a smaller dose should be used whenever 
possible. Of the manitol nitrate 1 grain seems to be sufficient. 

Nitroglycerin, equivalent to Spirit of Glyceryl Trinitrate. 

Glonon, a one-per-cent, by weight, alcoholic solution of nitro- 
glycerin. Dose, 1 to 2 TTt- This is slowly broken up in the body 
into nitrites and glycerin. It may produce severe headaches and 
dizziness on account of the meningeal irritation. 

Amyl Nitrite (Amylis Nitris; CgH^NO., = 116.24), miscible 
in all proportions with alcohol or ether; almost insoluble in water. 
Used as an antispasmodic in angina pectoris, dyspnea, asthma, 
fainting, cocain poisoning either by mouth or by inhalation. Av- 
erage dose, 3 drops (0.2 c.c.) in sweetened water. Antidotes: 
atropin, ergot, or strychnin used hypodermically. Inflammable. 
This drug takes effect in ten to fifteen seconds and lasts only a 
few minutes. The drug is usually prepared in a breakable sealed 
glass, to be broken in a handkerchief and held under the nostrils 
of the patient. 

Amyl nitrite produces dilation of the peripheral vessels with 
pronounced anemia of the pulmonary tissue; hence its value in 
hemoptysis. 

Sweet Spirits of Niter (Spiritus JEtheris Nitrosi), volatile, in- 
flammable, clear liquid of pungent odor and sharp, burning taste. 
Sp. gr. about 0.823. Diuretic, diaphoretic, antispasmodic. Aver- 
age dose, 30 TTt (2 c.c). Incompatible with antipyrin, acetan- 
ilid, or phenacetin, fluid extract buchu, morphin salts, and iodids 
(when it is acid). Must be kept in dark amber bottles, in a cool 
place, remote from light and fire. 

This is a four-per-cent alcoholic solution and used to be given 
regularly to produce diuresis, and is still used by the laity for that 
purpose. It seems to be quite ineffective for this purpose, but 
it does quite often produce some perspiration. The dosage varies 
from 1 to 4 c.c. 

Sodium Nitrite (Sodii Nitris; NaN0 2 = 68.57). — White, 
opaque masses, or pencils, or colorless, transparent crystals. Odor- 



438 MATERIA MEDICA 

less, of mild saline taste. Soluble in 1.4 parts water, slightly in 
alcohol. Antispasmodic, vaso-dilator, diuretic, also reagent. Av- 
erage dose, 1 grain (0.065 gram). Antidotes: sodium sulphanilate, 
naphthionic acid, emetics. Incompatible in solution with acetan 
ilid, antipyrin, hypophosphites, iodids, vegetable infusions, de- 
coctions, or tinctures, or mercury salts. Keep well stoppered, as 
on exposure it deliquesces and is oxidized to the nitrate. 

Nitrous Oxid. — Anesthesia by Undiluted Gas. — For very short 
operations (as in dentistry) the gas is inhaled through a tightly 
fitting mask, with the exclusion of air until the face becomes cy- 
anotic, the breathing stertorous, the pupils enlarged, and the 
patient unconscious. This occurs in sixty-three to eighty seconds. 
The gas is then removed and the operation performed at once, the 
anesthesia lasting only twenty-two to thirty seconds. The time 
from beginning the inhalation to complete recovery is only one 
hundred to one hundred and twenty seconds. There is very little 
nausea and no other after effect. The anesthesia is due to the com- 
bined action of the gas and of asphyxia, but mainly to the latter. 
It cannot, therefore, be prolonged. For short operations, it is the 
least dangerous of anesthetics. Only seventeen deaths have been 
reported, making a fatality of about 1 : 5,250,000. In case of 
accident, artificial respiration or, preferably, oxygen, should be 
applied. 

Anesthesia by Nitrous Oxid Diluted with Oxygen. — The 
anesthesia may be prolonged indefinitely by mixing the nitrous 
oxid with twenty per cent of oxygen and using it under an excess 
pressure of one fourth atmosphere. Even lesser proportions of 
oxygen permit a more or less lasting anesthesia. This principle 
has been utilized in practice. A special apparatus is required, al- 
lowing the mixture of two gases in any proportion. This is con- 
nected with a close-fitting mask. It is advisable to warm the gas 
mixture before it is inhaled. 

To hasten the anesthesia, the administration is begun with a 
mixture containing two per cent of oxygen. This is gradually in- 
creased to ten per cent. 

The induction of anesthesia is very rapid, perhaps twelve to 
fifteen minutes. The patients recover consciousness at once. The 
nausea is very slight, and with this method of administration there 
is no marked asphyxia — at most a slight cyanosis. The anesthesia 



MATERIA MEDICA 439 

is most readily induced in children or old people, is much more 
difficult in hysterics and alcoholics, sometimes failing entirely. 
The gas has, however, some disadvantages. Its administration re- 
quires skill and constant watching, since either recovery or as- 
phyxia occur very rapidly. The muscular relaxation is not nearly 
so complete as with ether. 

This method of anesthesia has proved especially valuable as a 
preliminary to other anesthesia. Its principal drawback is the 
expense and inconvenience of the apparatus and the expense of 
the gases. 

(By great skill and care in regulating the distance of the mask 
from the face, a prolonged anesthesia may be kept up with nitrous 
oxid, without oxygen.) (Sollmann.) 

Opium (Gum Opium), concrete milky exudation obtained by 
incising the unripe capsules of Papaver somniferum (Fam. Papa- 
veraceae). Asia Minor and India. Irregular, rounded masses of 
cakes, grayish brown externally, dark brown internally, plastic 
when fresh, of strong, narcotic odor and bitter taste. Antidotes: 
potassium permanganate (2 grains in solution) ; emetics: atropin 
or strychnin hypodermically ; hot strong coffee; exercise. 

The active principles are morphin, 10 per cent; codein, which 
is really methyl morphin, 0.5 per cent; narcotin, 0.6 per cent; 
papaverin, 1 per cent; thebain, which has a strychnin action, 0.3 
per cent. There are also three artificial alkaloids, all derived by 
chemical changes from morphin, thus: heroin is diacetylmorphin, 
dionin is ethylmorphin, peronin is benzylmorphin. 

The general action of opium may be said to be (1) the simul- 
taneous stimulation and depression of different parts of the central 
nervous system. Thus it depresses the perceptive powers of the 
hemispheres so that the attention of the patient is weakened and 
small impulses are not recognized. Memory also suffers. An in- 
crease in the size of the dose gradually cuts off the perceptive 
powers from the other parts of the nervous system. 

Opium has (2) a local action, when taken by the mouth, on the 
peristaltic mechanism of the intestine. This action is also mani- 
fested by morphin when given hypodermically, since the morphin 
is excreted from the circulation into the stomach. 

(3) Large doses paralyze the heart muscle. 



440 MATERIA MEDICA 

(4) The respiratory center is depressed. The result is that the 
volume of air respired is diminished. The amount of carbonic 
acid in the blood is increased, and we frequently have the phe- 
nomena of the Cheyne-Stokes respiration. 

Morphin is rapidly absorbed in the intestinal canal, and when 
absorbed lessens the metabolism of the body. The sweat is in- 
creased through the dilation of the cutaneous vessels. The num- 
ber of leukocytes is decreased. The excretion takes place through 
saliva and gastric juices to the extent of sixty-six per cent, but 
enough goes through the urine to cause sometimes a reduction of 
copper on account of the presence of morphin — glycuronic acid. 
It should be noted in this connection that some morphin is ex- 
creted in the milk, which makes the drug inadvisable to use for 
nursing mothers. A single dose disappears entirely from the body 
in two days. 

Small doses of morphin dilate the cutaneous vessels. Large 
doses, however, make the skin appear blue because the dilation 
of the vessels of the splanchnic area has taken so much blood that 
there is none left to fill the skin in spite of the local dilation. Un- 
der such circumstances the skin may become cyanotic. 

The pupils are contracted through the paralysis of the medul- 
lary pupillo-dilator center. 

There is no local action of the drug and it is very slightly ab- 
sorbed through the skin, therefore to paint it on the skin for the 
sake of lessening pain in the deeper structures is not as wise as 
it would be to select some other drug such as atropin or aconite, 
either of which is readily absorbed. 

It should be remembered that morphin follows the general law, 
and while large doses depress the cardiac muscle, small doses stim- 
ulate it. 

Acute poisoning from morphin should be treated by gastric lav- 
age. The best solution is potassium permanganate, because this 
has the power to oxidize the morphin and thus render it innocuous. 
Inasmuch as the morphin is excreted into the stomach, the gastric 
lavage must be repeated until there is practically no more of the 
drug in the body to be excreted into the stomach. As stimulant, 
coffee is the best. The fatal dose varies from 3 to 6 grains. The 
fatal dose of opium is 3 grams. 

Heroin depresses the respiratory and cough reflex centers be- 



MATERIA MEDICA 441 

sides increasing the venosity of the blood. It is interesting to note 
that while the rate of respiration is decreased fifty per cent, the 
volume of each respiration through the action of heroin is in- 
creased by forty per cent. There is hardly any action on the ali- 
mentary canal. 

The action of Codein is midway between morphin and he- 
roin. 

Dionin has a specific action on the conjunctiva, causing a local 
hyperemia and irritation followed by anesthesia. 

The general indication for opium and morphin is pain. It 
should be used for insomnia only when that insomnia is due to 
pain. In this connection it is wise to note that the phenomena of 
pain may be checked by depressing the perceptive center (as by 
morphin), by blocking the transmitting nerve fiber (as by cocain), 
and finally by paralyzing the end organ of the sensory nerve (as 
by atropin). Whenever it is possible, it is best to use the latter 
type of analgesia because it interferes less with the general 
organism. 

Opium is better than morphin for checking peristalsis in diar- 
rhea and peritonitis, and for this purpose is usually given in the 
form of the tincture in doses from three to twenty drops. It may 
be given by the rectum when it is unwise to pass it through the 
stomach. In this case, a larger dose by one fourth should be given 
than when given by the mouth. 

Before severe operations a hypodermic dose of morphin will 
be found very useful in quieting the patient and making him 
ready for the anesthetic. In fact, when combined with hyoscin 
(tJtt)* the patient may be put to sleep so completely that ordinary 
operations may be performed without awaking him. 

The celebrated " Dover's powders " are an apparent contra- 
diction, because the opium would seem to be used to depress the 
reflexes from the intestinal canal, while the ipecac would exalt 
them. However, the value of the opium in this combination is that 
it dilates the capillaries of the skin and thus produces hyperemia 
and perspiration. It is indicated, if at all, therefore, in such con- 
ditions as beginning colds. 

In using heroin for cough, care should be taken to avoid the 
vertigo which sometimes accompanies the use of this drug. This is 
best accomplished by keeping the patient flat on his back. 



442 MATERIA MEDICA 

The nauseating effect of morphin is usually counteracted by 
atropin (tVo-^to grain), especially when given hypodermically. 

The preparations of opium are : Powdered opium, dose J to 2 
grains. This ordinarily contains from twelve to twelve and one 
half per cent morphin. Dover's powders, which contain ten per 
cent each of powdered ipecac and opium; dose, 5 to 15 grains. 
Laudanum, which is a tincture made up half alcohol and half 
water, containing ten per cent of the powdered opium, that is, one 
and one fourth per cent morphin ; dose, 3 to 20 drops. Deodorized 
tincture of opium is one fifth alcohol; dosage, the same as lauda- 
num. Camphorated tincture of opium (paregoric) should be used 
in teaspoonful doses, which would make the content of opium in 
such a dose (4 c.c.) 4 grain. For a baby two days old, 2 drops 
should be the dose; for a child two years old, 12 drops should be 
the dose. 

The alkaloids, morphin: Of the salts of morphin, the acetate 
is the most soluble, then the hydrochlorid. The dose varies 
from -J to J grain. Codein is usually used in the phosphate; dos- 
age, | to 2 grains. Narcotin, dose, 3 grains. Heroin, dose, T V to 
£ grain. Dionin is used in a ten-per-cent ointment for trachoma. 

Orthoform is the methyl ester of metamidoparaoxybenzoic acid, 
C 6 H 3 OH.NH 3 COOCH 3 , white, bulky, inodorless, tasteless powder. 
Soluble readily in alcohol, ether, or collodion; sparingly in water. 
Local anesthetic and analgesic. Dose, 7J to 15 grains. 

Orthoform is very slowly absorbed, but rapidly excreted. It 
should, therefore, never be given hypodermically and is of no value 
when rubbed into the skin. It may be used as a dusting powder 
with bismuth for its antiseptic effect (benzoic-acid effect), or it 
may be used on the skin in the form of an ointment in the strength 
of ten to twenty per cent in the case of parasites, or even for 
abrasions. When used internally, a dose of five grains in a one- 
per-cent solution on an empty stomach seems sometimes to be ef- 
fective in relieving the pain of gastric ulcer and erosion. 

Ox Gall. Fel Bovis, the fresh bile of bos taurus Linne. A 
brownish-green, somewhat viscid liquid, having a peculiar, un- 
pleasant odor and a disagreeable, bitter taste. 

Specific gravity, 1.015 to 1.025 at 25° C. (77° F.). 

It is neutral or has a faintly alkaline reaction upon litmus 
paper. 



MATERIA MEDICA 443 

Purified Ox Gall. — Ox gall, 300 c.c. ; Alcohol, 100 c.c. A yel- 
lowish-green, soft solid, having a peculiar odor and a partly sweet 
and partly bitter taste. 

Very soluble in water and in alcohol. 

An aqueous solution of purified ox gall should be clear, and 
should remain transparent upon the addition of an equal volume 
of alcohol (evidence of proper purification). 

Dose: 0.500 gram = 500 milligrams (7J grains). (U. S. P.) 

Pancreatin (Pancreatinum) . — It should be remembered that 
the pancreatic ferments act only in an alkaline medium. In order 
to be given effectively, they must, therefore, not be destroyed in the 
stomach. 

A combination of pancreatic ferments should digest twenty-five 
times its weight in starch. An excellent comparison of the di- 
gestive ferments in the market is found in the Journal of the Amer- 
ican Medical Association for July 11, 1908. According to this 
comparison, holadin is the most efficient starch digestant. 

Pancreatin is a mixture of enzymes naturally existing in pan- 
creas of warm-blooded animals, and obtained from pancreas of the 
hog. (Sus scrofa.) Cream-colored, amorphous powder, of faint, 
not unpleasant, odor and somewhat meatlike taste. Slowly soluble 
in water (more than ninety per cent) ; insoluble in alcohol. In- 
compatible with pepsin, mineral acids in greater concentration 
than 0.5 per cent, concentrated alkalies, alcohol. Average dose, 
7J grains. 

Pancreatin should be given on an empty stomach, or when the 
chyme is rapidly passing into the duodenum. It should be given 
with soda or ox gall, or both; or else should be given in a salol 
capsule. 

Holadin presents all the constituents of the pancreas gland, 
both of the digestive and of the internal secretion. Holadin, while 
possessing great tryptic activity, is of special potency in respect 
to the amylolytic and lipolytic enzymes ; it is rich in the important 
cell constituents, lecithin, and nuclein, which peculiarly abound 
in the pancreas. 

Holadin is offered in gelatin capsules, each containing about 
0.185 gram, approximately 3 grains. The usual dose is one cap- 
sule about three hours after meals and one at bedtime. In cases 



444 MATERIA MEDICA 

of constitutional disease, or in serious disorders of digestion at- 
tributed to faulty pancreatic functioning, the dose may be gradu- 
ally increased to two or three capsules at a time. 

Holadin may be obtained combined with the bile salts in the 
proportion of 2\ grains holadin to J grain bile salts, put up in 
capsules. The dose is one capsule two to three hours after eating. 

Diazyme Essence is a liquid stated to contain the amylolytic 
enzyme of the pancreas, devoid of trypsin and lipase in a men- 
struum containing 18.5 per cent of alcohol by volume. 

Diazyme essence is an amber fluid of aromatic taste and odor 
and slightly acid reaction. 

One c.c. will convert at 40° C. 200 grams of pure starch 
mucilage, containing 8 grams of dry starch, so that the solution 
will cease to give a color reaction with iodin at the end of ten 
minutes. 

Dose: 4 to 8 c.c. (1 to 2 fluid drams). 

Diazyme Glycerole is a liquid stated to contain the amylo- 
lytic enzyme of the pancreas, devoid of trypsin and lipase, in a 
menstruum containing about sixty per cent of glycerin by volume. 
It is a dense amber fluid of agreeable taste and odor and of 
slightly acid reaction. One c.c. will convert at 40° C. 200 grams 
of pure starch mucilage, containing 8 grams of dry starch, so that 
the solution will cease to give a color reaction with iodin in ten 
minutes. This should also be given two to three hours after 
food. 

Papain. — Papain, papayotin, and papoid are names given to a 
digestive ferment derived from the juice of Carica papaya. This 
ferment possesses the power of changing proteids into peptones 
in the presence of an acid or an alkali, or even in a neutral mix- 
ture, thereby differing from pepsin and pancreatin. This power 
would be of great value, since the drug would then be useful in 
all forms of dyspepsia, were it not that careful experimentation 
renders it doubtful whether papain, papayotin, or papoid can 
really supplant either of the animal ferments named above. The 
dose of all these products is from 1 to 8 grains (0.06 to 0.50) given 
in solution or, better, in capsule. 

Peppermint (Mentha Piperita, U. S. P.) is official in the form 
of dried leaves and tops of Mentha piperita. It has an aromatic 
odor and taste and contains oil. Locally applied, the oil acts as 



MATERIA MEDICA 445 

an irritant and local anesthetic. From this oil is obtained men- 
thol, a camphoraceous substance of a hot, burning taste, possessing 
marked power as a local anesthetic. 

Peppermint is used in the form of the oil (Oleum Menthae 
Piperita?, U. S. P. and B. P.), dose, 1 to 4 Hi (0.06 to 0.25) ; the 
spirit (Spiritus Menthae Piperita?, U. S. P. and B. P.), dose, 10 to 
30 Hi (0.60 to 2) ; the water (Aqua Mentha? Piperita?, U. S. P. 
and B. P.), dose, 1 to 2 drams (4 to 8) ; and, finally, as the troches 
(Trochisci Menthae Piperitae), to be held in the mouth in indefinite 
number. 

Pepsin (Pepsinum, U. S. P. and B. P.) is the digestive ferment 
of the gastric juice. That sold in the shops is generally derived 
from the pig, and is prepared by manufacturers in many ways. 
Much of the pepsin of the market contains more peptone than 
pepsin, and much mucus and albumin. Used with hydrochloric 
acid in weak solution, pepsin carries out the digestive action of 
the stomach. Pepsin containing peptone has the peculiar musty 
smell of peptone, and if the peptone is in excess will absorb 
moisture and become sticky on exposure to the air. 

Permanganate of Potassium (Potassii Permanganas, U. S. P. 
and B. P.) is a salt of a dark purplish-red color, appearing in small 
crystals and readily soluble in water. In the presence of moisture 
it rapidly gives up the oxygen which it contains and becomes the 
dioxid of manganese. 

By reason of its oxidizing power the permanganate of potas- 
sium is useful as an antiseptic and deodorant. It should not be 
employed as a disinfectant for filth, because its action is too fleet- 
ing, but in saturated solution, followed by oxalic-acid solution, 
it proves itself one of the best disinfectants for the hands in sur- 
gical practice. 

For irrigating the vagina and bladder it is used in 1 : 4,000 
solution. In gastric lavage following morphin poisoning it may 
be used as strong as 1 : 1,000. 

Petrolatum (Petrolatum Molle, Petrolatum, Spissum, Pharm., 
1890), a mixture of hydrocarbons, chiefly of the methane series, 
obtained by distilling off the lighter and more volatile portions 
from petroleum and purifying the residue. 

Petrolatum is insoluble in water; scarcely soluble in cold or 
hot alcohol, or in cold, absolute alcohol, but soluble in boiling ab- 



446 MATERIA MEDICA 

solute alcohol, and readily soluble in ether, chloroform, carbon 
disulphid, oil of turpentine, petroleum benzine, benzene, and fixed 
or volatile oils. 

The melting point of petrolatum ranges between 45° and 48° 
C. (113° and 118.4° F.). (U. S. P.) 

Phenol (Acidum Carlolicum, Pharm., 1890; C 6 H 5 OH = 93.34), 
Hydroxylbenzene, obtained either from coal tar by fractional dis- 
tillation and subsequent purification, or made synthetically. It 
should contain, when assayed, not less than ninety-six per cent of 
absolute phenol. It should be kept in dark amber-colored, well- 
stoppered bottles. 

Soluble in 19.6 parts of water at 25° C. (77° P.), the solubility 
varying according to the degree of hydration of the phenol; very 
soluble in alcohol, ether, chloroform, benzene, carbon disulphid, 
glycerin, fixed and volatile oils; almost insoluble in petroleum 
benzine. 

When gently heated, phenol melts, forming a highly refractive 
fluid. It is also liquefied by the addition of about eight per cent 
of water. If the phenol be liquefied by a gentle heat, and then 
slowly cooled under constant stirring until it is partly recrystal- 
lized, the semiliquid mass should have a temperature (remaining 
stationary for a short time) not lower than 40° C. (104° P.). 

Phenolphthalein (C 20 H 14 OJ is a product of the interaction of 
phenol and phthalic anhydrid. 

It may be prepared by heating together 10 parts of phenol, 
5 parts of phthalic anhydrid, and 4 parts of concentrated sul- 
phuric acid for ten to twelve hours, at 115° to 120° C. (239° to 
248° F.). The product of the reaction is boiled with water and 
the residue dissolved in soda lye. From this solution the phenol- 
phthalein is precipitated by the addition of acetic acid. The pre- 
cipitate, after washing, is dissolved in six times its weight of abso- 
lute alcohol and the solution decolorized by animal charcoal. A 
part of the alcohol is then distilled, the mixture filtered, and the 
phenolphthalein separated from the filtrate by the addition of 
water. 

Phenolphthalein occurs as a crystalline or amorphous powder, 
white or grayish white, melting at 250° to 253° C. (482° to 487.4° 
F.). It is soluble in 600 parts water and in 10 alcohol. Its solu- 
tions in acid liquids are colorless, but turn red when the liquid is 



MATERIA MEDICA 447 

alkaline. The red color of the solution disappears if it is boiled 
with zinc dust, phenolphthalein, C 20 H 16 O 4 , being formed. 

Dose: For adults the average dose is 0.1 to 0.2 gram (1.5 to 3 
grains), given as powder in cachets, capsules, or pills. It may be 
given with safety in doses of 0.5 gram (8 grains), and these doses 
seem to be necessary to secure its effects in bedridden patients or 
in obstinate cases. 

Phosphorus (P = 30.77). — It should contain not less than 99.5 
per cent of pure phosphorus, and be carefully kept under water, 
in strong, well-closed vessels, protected from light. 

A translucent, nearly colorless solid, of a waxy luster, having, at 
ordinary temperatures, about the consistence of beeswax. By long 
keeping, the surface becomes white or red, and occasionally black. 
It has a distinctive and disagreeable odor and taste (but should 
not be tasted, except in very dilute solution). When exposed to 
the air it emits white fumes, which are luminous in the dark, 
and have an odor somewhat resembling that of garlic; on longer 
exposure to air it often takes fire spontaneously. 

Specific gravity: 1.830 at 10° C. (50° F.) and 1.820 at 25° C. 
(77° F.). 

Melting point: 44° C. (111.2° F.). 

Phosphorus is insoluble, or nearly so, in water, to which, how- 
ever, it imparts its characteristic, disagreeable odor and taste; 
soluble in 350 parts of absolute alcohol at 15° C. (59° F.), in 240 
parts of boiling absolute alcohol, in 80 parts of absolute ether, 
in about 50 parts of any fatty oil, and in about 25 parts of chloro- 
form; it is very soluble in carbon disulphid, the latter yielding 
a solution which must be handled with the greatest care to prevent 
evaporation, which would be followed by instant ignition. (U.S.P.) 

Piperazin. — Mucus is decomposed by the action of the alkalies, 
but it has been found that the urates and mucus collected in in- 
flammation of the urinary tract are better decomposed by the 
organic bases. These, however, accomplish little in the presence 
of sodium salts. Therefore, for vesical calculi, at least, irrigation 
is the best method of treatment, and piperazin in from one- to five- 
per-cent solution forms the best solution. The tartrate of dimethyl 
piperazin is called lycetol, and is used in the dose of 1 gram (15 
grains) three times a day. The dose for piperazin is the same. 

Lysidin, the hydrochlorate of ethylin-diamin, is more solvent 
30 



448 MATERIA MEDICA 

than piperazin. Ethylin-diamin has been used for dissolving false 
membranes. 

Pollantin (Fall, Dunbar's Serum), an antitoxic serum from 
horses treated with pollen toxin derived from ragweed. 

Horses are injected with gradually increased doses of pollen 
toxin (derived from ragweed), which results in the formation of 
an antitoxin after two or three months of treatment. The horses 
are then bled and the strength of the serum is estimated by de- 
termining the proportion which will prevent the action of a solu- 
tion of pollen toxin, of which one drop is barely sufficient to 
produce a reaction when instilled into the conjunctival sac of a 
hay-fever patient. The serum is preserved by the addition of 0.25 
per cent of phenol. 

It is a clear, slightly yellowish liquid, having the odor and taste 
of a dilute solution of phenol. On standing, the liquid deposits a 
slight precipitate. The liquid is alkaline in reaction and not irri- 
tating to the normal conjunctiva. 

It should neutralize the effects of a solution of pollen toxin 
when mixed with it and dropped into the eye or when a drop is 
applied immediately after a drop of the toxin solution. 

The liquid does not keep well if exposed to the air. When it 
becomes cloudy or a bad odor develops, decomposition has occurred 
and the preparations should no longer be used. 

Dose: One drop should be instilled by means of a pipette into 
the outer angle of each eye and one or two drops into one nostril, 
the other being kept closed, every morning before rising. If the 
first application causes sneezing or reddening of the mucous mem- 
brane of the eye, it is recommended to repeat the application, even 
for the fourth time, if necessary. (N. N. R.) 

Potassium Compounds. — Potassium Acetate (KC 2 H 3 2 = 
97.44). It should contain, when thoroughly dried, not less than 
ninety-eight per cent of pure Potassium Acetate (CH 3 .COOK), 
and should be kept in well-stoppered bottles. 

A white powder, or in crystalline masses of a satinlike luster, 
odorless, and having a warming, saline taste. Very deliquescent 
on exposure to the air. 

Soluble in 0.4 part of water and in 2 parts of alcohol at 25° C. 
(77° F.) ; with increasing temperature it becomes much more solu- 
ble in both liquids. 



MATERIA MEDICA 449 

Potassium Bromid (KBr = 118.22). — It should contain not 
less than ninety-seven per cent of pure Potassium Bromid, and 
should be kept in well-stoppered bottles. 

Colorless, or white, cubical crystals, or a granular powder; 
odorless, and having a strongly saline taste. Permanent in the 
air. 

Soluble in about 1.5 parts of water and in about 180 parts of 
alcohol at 25° C. (77° F.) ; in less than 1 part of boiling water, 
and in 16 parts of boiling alcohol; also soluble in glycerin. 

Potassium Chlorate (KC10 3 == 121.68). — It should contain 
not less than ninety-nine per cent of pure Potassium Chlorate 
(ClOoOK), and should be kept in well-stoppered bottles. Great 
caution should be observed in handling it, as dangerous explosions 
are liable to occur when it is heated or subjected to concussion or 
trituration with organic substances (cork, tannic acid, sugar, etc.) 
or with sulphur, antimony sulphid, phosphorus, or other easily 
oxidizable substances. 

Colorless, lustrous, monoclinic prisms or plates, or a white, 
granular powder; odorless, and having a cooling, characteristic 
taste. Permanent in the air. 

Soluble in 16 parts of water at 25° C. (77° F.), and in 1.7 
parts of boiling water; insoluble in absolute alcohol, and but 
slightly soluble in diluted alcohol. The drug is irritant to the kid- 
neys and should be used with great caution. 

Effervescent Potassium Citrate. — Potassium Citrate, 200 
grams ; Sodium Bicarbonate, dried and powdered, 477 grams ; Tar- 
taric Acid, dried and powdered, 252 grams; Citric Acid, unef- 
floresced crystals, 162 grams. To make about 1,000 grams. 

Potassium Iodid (KI = 164.76). — It should not contain less 
than ninety-nine per cent of pure Potassium Iodid, and should be 
kept in well-stoppered bottles. 

Colorless, transparent, translucent, or opaque white, cubical 
crystals, or a white granular powder having a peculiar, faint, 
iodinlike odor, and a pungent, saline, afterwards bitter taste. 
Permanent in dry air, and but slightly deliquescent in moist 
air. 

Soluble in 0.7 part of water, and in about 12 parts of alcohol 
at 25° C. (77° F.) ; in 0.5 part of boiling water, and in 6 parts 
of boiling alcohol; also soluble in 2.5 parts of glycerin. (U.S. P.) 



450 MATERIA MEDICA 



Quinin (Quinina; C 20 H 24 N 2 O 2 HC 2 H 3 O 2 = 375.46), white, odor- 
less, bitter, slightly efflorescent powder. Soluble in 1,750 parts 
water, 0.6 alcohol, 4.5 ether, 1.9 chloroform, 158 glycerin. Average 
dose, 4 grains (0.25 gram). 

This is derived from the cinchona bark. Its actions may be 
summarized as follows : ( 1 ) It has a toxic action on all protoplasm, 
and inhibits ferment action. (2) It seems to have specific toxicity 
for the malarial organism. (3) It diminishes the production of 
heat and fever by a direct depression of the centers controlling 
heat production. (4) It depresses the central nervous system after 
a slight preliminary stimulation. 

The heart is weakened by doses of one gram and upward. 
This is accompanied by a vaso-dilation, which makes a collapse more 
probable. 

Locally, it causes irritation which may even reach the point of 
abscess formation. Striped muscle is irritated and weakened, while 
smooth muscle ordinarily shows no reaction, in spite of the popular 
belief that quinin stimulates the contraction of uterine fibers. 
It is interesting to note that the hemoglobinuria in malaria is often 
due to quinin rather than to malarial organisms. Since quinin 
inhibits ferment action, it is well adapted for use as a bitter tonic 
in stomachic combinations. The signs of intoxication are ringing 
in the ears, photophobia, etc., and are probably due to the local 
effect on specialized organs. 

In malaria the drug should be given in such a way that there 
is present in the blood stream 1 gram of the quinin at the time 
of the division of the plasmodia, that is, at the time of the outbreak 
of the fever. To accomplish this, we ordinarily give J gram eight 
hours before the time of the expected chill, and J gram four 
hours later. 

Quinin decreases the size of the spleen, especially in cases of 
enlarged spleen (Splenomegaly). 

Quinin is useful in neuralgias in connection with the bromids. 
Thus you would give a dose of 1 gram of bromid and ^ gram 
of quinin in sufficient flavored water to make a pleasant solu- 
tion. 

It should be remembered that the bisulphate is soluble in 8J 
parts of water, while the sulphate is only soluble in some hundreds 
(740) of parts of water. The hydrochlorid is soluble in 18 parts. 






MATERIA MEDICA 451 

For this reason the bisulphate should ordinarily be chosen as the 
salt for use, especially for colonic irrigation. 

Quinin is excreted through the urine, and the excretion begins 
one hour after absorption. 

Resorcin (Resorcinol; C 6 H 6 2 = 109.22), a diatomic phenol 
(metadihydroxybenzene, C 6 H 4 (OH 2 ) 1:3), obtained usually by 
the reaction of fused sodium hydroxid upon sodium metabenzene- 
disulphonate. Resorcinol should be kept in dark amber-colored 
vials. 

Colorless, needle-shaped crystals, having a faint, peculiar odor 
and a sweetish, followed by a bitter, taste. It acquires a pinkish 
tint on exposure to light and air. 

Soluble in 0.5 part of water at 25° C. (77° F.), slightly soluble 
in boiling water or in boiling alcohol ; also readily soluble in ether 
and glycerin; very slightly soluble in chloroform, carbon di- 
sulphid, and benzene. (U. S. P.) 

Rhubarb (Rheum, U. S. P.; Rhei Radix, B. P.) is the root of 
several species of Rheum, a plant of Thibet, but which is cultivated 
in America and elsewhere. It is also derived from China, and this 
variety is known as Chinese rhubarb. Several alkaloids are con- 
tained in it, all of which are unimportant and never used alone, 
except chrysophanic acid. 

Owing to the astringent properties possessed by rhubarb, it 
does not purge excessively, and improves the appetite, digestion, 
and intestinal tone. Its constant use produces chronic consti- 
pation. 

Rhubarb, because of its chrysophan, may stain alkaline urine 
carmin, or acid urine yellow. 

Rochelle Salts (Potassium and Sodium, Tartrate; KNaC 4 H 4 6 
+ 4H 2 = 280.18). — It should not contain less than ninety-nine 
per cent of pure Potassium and Sodium Tartrate (C 2 H 2 (OH) 2 - 
(COOK)(COONa) +4H,0), and should be kept in" well-stop- 
pered bottles. 

Colorless, transparent, rhombic prisms, or a white powder, odor- 
less, and having a cooling, saline taste. The crystals slightly ef- 
floresce in dry air. 

Soluble in about 1.2 parts of water at 25° C. (77° F.), and in less 
than 1 part of boiling water; almost insoluble in alcohol. (U. S. P.) 



452 MATERIA MEDICA 

Sabromin was originated by von Mering, of Halle, and Fischer, 
of Berlin, and is a calcium salt of dibrombehenic acid. It contains 
about 29 per cent bromin and 3.8 per cent calcium, and appears 
as a white, odorless, and tasteless powder of neutral reaction, in- 
soluble in water and alcohol. If protected against light, it remains 
unchanged. 

Pharmacological experiments have shown that sabromin is 
practically nonpoisonous, since it was well tolerated by medium- 
sized dogs in 10-gram doses, without causing any toxic phe- 
nomena. 

The excretion of sabromin by way of the urine takes place very 
slowly and extends over several days. As sabromin is insoluble 
in water and ordinary solvents, it can be administered in powder 
form, wafers, or, best of all, in tablets. It has been introduced in 
the form of tablets of 8 grains each. 

Salicylates are white powders or crystals, turning pink on ex- 
posure; disagreeable, sweetish taste. The solutions soon acquire 
a brown color. Dose, 0.3 to 2 grams (5 to 30 grains). 

One part is soluble in Water Alcohol 

Sodii salicylas (U. S. P., B. P.), NaC 7 H 5 3 . 0.8 5.5 

Ammonii salicylas (U. S. P.), NH 4 C 7 H 5 3 . 0.9 2.3 

Lithii salicylas (U. S. P.), Li.C 7 H 5 3 Very soluble 

Strontii salicylas (U. S. P.), Sr(C 7 H 5 3 ) 2 . . 18.0 66.0 

Salicylates are incompatible with acids. 

Salicylic Esters (Methyl Salicylate; CH 3 C 7 H 5 3 ) exists in 
three forms: 

As a synthetic product — Methyl salicylas (U. S. P.). 

As the volatile oil of Betula lenta — Oleum betulae volatile (U. 
S. P.), Oil of Sweet Birch. 

As the volatile oil of Gaultheria procumbens — Oleum Gaul- 
theria? (U. S. P.), Oil of Wintergreen. 

The dose of these is 0.05 to 1 c.c. (1 to 15 lit). (1 c.c. = 15 lit, 
U. S. P.) Soluble in all proportions of alcohol; very sparingly in 
water. They are less irritant and disagreeable, but also much less 
active, than the solium salicylate. 

Aspirin (Acetyl-salicylic Acid), white needles, acidulous taste. 
Soluble in 100 water. Incompatible with alkalies. Dose, 1 gram 
(15 grains), in powders. 



MATERIA MEDICA 453 

Mesotan (Methyloxy methyl- salicylic Acid), clear, yellow, 
faintly aromatic fluid, almost insoluble in water ; soluble in alcohol 
and in oils. Readily absorbed by the skin from its oily solution. 
It is used by rubbing a teaspoonful of a mixture of equal parts of 
mesotan and olive oil into the skin at the site of the rheumatic 
pain. (Dreser, 1903.) 

Salophen (Aceto-para-amido-salol) , colorless crystals, insolu- 
ble in water, soluble in alcohol. Dose, 1 to 2 grams (15 to 30 
grains) . 

Salicinum (U. S. P., B. P.; C 13 H 18 7 ), a glucosid derived from 
several species of willow and poplar. Soluble in 21 parts of water 
or 71 of alcohol. Dose, 0.3 to 2 grams (5 to 30 grains). 

Saline Solution. — Various formulae exist for the preparation of the 
so-called normal saline solution. Some persons are satisfied to employ 
the ordinary solution of common salt in the strength of 0.7 per cent 
(1£ drams to a quart) in distilled and sterilized water, but this is a dan- 
gerous plan, for the reason given below. 

Very slight variations in the percentage of normal saline solution 
render it harmful. While 0.7 to 0.9 may be considered permissible, a 
solution lower than 0.6 should not be used, because of the deleterious 
effects on the red blood cells, and also because it will abstract salts from 
the tissues. If the solution is too strong it will cause the cells to 
shrivel. 

It is evident, therefore, that an absolutely correct percentage is 
essential if salt solutions are to be employed. Many years ago Dr. Syd- 
ney Ringer, in London, found by accident, and proved by careful ex- 
periment, that a small quantity of calcium was essential to the satis- 
factory use of a sodium chlorid solution. Later than this Loeb, Howell, 
Locke, and others have shown, with Ringer, that calcium and potas- 
sium are both essential, and Howell has concluded that the sodium 
maintains the proper osmotic relations between the cells and the fluid, 
that the calcium is a stimulating agent to the heart and muscle, and 
that potassium is essential to its rhythmical contraction and relaxation. 

Surgeons and physicians should not be content to employ salt solu- 
tions prepared by haphazard methods. It is vitally important that these 
solutions shall be most accurately prepared, not only because they will 
fail to be of benefit if they are carelessly used, but also because the 
physician may do actual damage and impair his patient's chances of 
recovery if such care is not followed. 

In addition to the effects which may be exercised upon the blood 
and its serum, it is interesting to note that Brown has shown that the 



454 MATERIA MEDICA 

use of pure sodium chlorid solutions is not infrequently followed by 
glycosuria, whereas if calcium is added to the solution such a leakage 
of sugar does not take place. The old rule, therefore, that the normal 
salt solution may be made by adding a teaspoonful of common salt to a 
pint of water ought never to be followed if it can be avoided. Mathews 
also believes, and I heartily agree with him, that when large quantities 
of fluid are used in the peritoneal cavity, calcium and potassium should 
be present in addition to sodium chlorid in normal quantities. 

The best solution, because it at once supplants the blood which has 
been lost or is impure, and because it supports the heart, is : 

Calcium chlorid 0.25 gram. 

Potassium chlorid 0.1 

Sodium chlorid 9.0 " 

Sterilized water 1,000 c.c. 

At the author's suggestion, there is now placed upon the market 
a " concentrated saline solution," in which the salts just named are dis- 
solved in 1 ounce of sterile water and placed in a sealed sterile bottle. 
The contents of one of these vials added to 1 quart (1,000 c.c.) of pure 
sterile water make a normal saline fluid ready for instant use. The 
dry salts, carefully sterilized, are also marketed. 

The method of injection is as follows: The thoroughly sterilized 
saline solution, after being warmed to the temperature of 101° F., is 
placed in a warm glass irrigation flask. The patient's skin over the 
elbow is bared and sterilized; the skin over one of the veins, which is 
made prominent by a bandage about the upper arm, is incised by a 
scalpel, and the sheath of the vein raised by means of a pair of dissect- 
ing forceps. This sheath is thoroughly dissected off the vein until this 
vessel lies free from any attachments for the space of half an inch. A 
small and gentle bulldog clip is applied on the vein at the proximal 
end of the incision, so as to keep the lower part of the vein full of blood. 
A ligature is now passed around the vein at the distal end of the in- 
cision and tied. Another ligature is then passed under the vein and 
left untied. The distended area of the vein, between the ligature which 
has been tied and the clip, is now snipped by means of a pair of fine 
scissors, and a glass canula, previously dipped in the saline solution to 
prevent the few drops of blood from coagulating on its tip, is inserted 
into the opening in the vein. The loose ligature is now tied around it 
and the vein to hold the canula in place. This canula should have a 
shoulder at its tip to prevent the ligature from slipping off, and its 
other end should be attached to a piece of sterile rubber tubing not more 
than four inches long. By means of a sterilized glass pipette some of 



MATERIA MEDICA 455 

the saline is now run into the rubber and glass canula until all air is 
displaced and they are filled to the utmost. The saline is then allowed 
to flow out of the tubing attached to the irrigator, which is armed by a 
glass tip, until all the air is displaced, when one tube is slipped inside 
the other. By this means all danger of air embolism is excluded. The 
irrigator is now held about two feet above the arm and the fluid al- 
lowed slowly to enter the vein, a half hour being spent in injecting 
about a quart. As the injection is given the pulse begins to improve, 
the respirations are deeper and less hurried, and if fever is present the 
temperature usually falls. The patient is evidently better, but soon 
enters the critical stage, which may come on in from two to thirty 
minutes. There are sometimes a violent chill, a strong, rapid pulse, 
and in the course of three quarters of an hour a flushing of the skin, 
followed by a profuse sweat. The respiration may be labored. The 
urinary flow is also increased, and sometimes water escapes from the 
bowel. Several hours later the real benefit appears in convalescence or 
in marked improvement. (Quoted from Hare's Therapeutics.) 

Salol (Phenylis Salicylas, Phenyl Salicylate; C 13 H 10 O 3 ), sali- 
cylic ester of phenyl. White, crystalline powder of slightly 
aromatic odor and taste. Very sparingly soluble in water, readily 
in 5 parts alcohol, very freely in hot alcohol, ether, chloroform, 
and oils. (U.S.P.) 

This is broken up in the presence of an alkaline medium. It 
is rarely decomposed in the stomach, but it is slowly but com- 
pletely decomposed in the intestine. The salicylic acid is valuable 
as a disinfectant in the bile ducts and kidneys; the phenol action 
is valuable in the intestines. Because of its insolubility salol is 
used as a coating for enteric pills. It is also used as an intestinal 
antiseptic in typhoid fever and similar disorders. It is used as 
urinary and biliary antiseptic also. The ordinary dose is one half 
gram. The indications of systemic intoxication are either satura- 
tion of the urine with phenol or ringing in the ears. The urine 
is only weakly antiseptic in salol. (Sollmann, Journal American 
Medical Association, September 5, 1908.) 

Sandalwood Oil (Oleum Santali, U. S. P, and B. P.) is derived 
from the wood of Santalum album, a tree of India, and has a hot, 
burning taste. The odor is very pleasant and the oil has been 
used as a perfume. In overdose the oil is capable of producing 
great irritation of the genito-urinary passages. 



456 MATERIA MEDICA 

• 
In all cases it should be given in capsule in the dose of 5 to 

20 TTl (0.30 to 1.3), 5 711 (0.30) being usually sufficient, although 

the druggists generally keep it in 10-TTt (0.60) capsules. Oil of 

sandalwood may irritate the stomach, but it is not so apt to do so 

as in cubebs or copaiba. 

Santonin (Santoninum, U. S. P. and B. P. J is a neutral prin- 
ciple derived from Levant worm-seed or Santonica, TJ. S., which 
is the unexpanded flower-heads of Artemisia pauciflora (Maritima, 
B. P.), a plant of Asia Minor and Turkestan. Santonin is soluble 
in alcohol and chloroform, but slightly so in water. Santoninic 
acid is formed by warming santonin with alkalies, and Hesse has 
found that santonin is an anhydrid of santoninic acid. Santoninic 
acid is more soluble than santonin. 

Poisoning. — Santonin causes, when taken in overdose, muscular 
tremors, convulsive movements, unconsciousness, and sometimes 
epileptiform convulsions. 

One of the most common symptoms of the poisoning is chroma- 
topsia or xanthopsia, during the existence of which all objects look 
yellow. This is due to the staining of the humors of the eye by 
the drug. This may go on to total blindness or pass away in a 
few days. If the vision is not yellow it may be green. The urine 
is also stained — first yellow, then saffron, and finally purple red, 
or is bloody looking. This is not due to the presence of blood, but 
to the drug. Poisonous doses of the drug do not cause gastro- 
enteritis. (Sollmann.) 

Senna (U. S. P.). — The leaflets of Cassia acutifolia (Senna 
Alexandrina, B. P.) (Alexandria Senna) or Cassia Angustifolia 
(Sinna Indica, B. P.) (India or Tinnevelly Senna) Leguminosae. 
Easter and Central Africa and India; cultivated. Dose, 5 to 15 
grams (1 to 41 drams). (4 grams = 1 dram, U. S. P.) The leaf- 
lets of the Indian senna are much longer than those of the Alex- 
andria variety. 

Senna produces considerable griping. This may be almost 
abolished without greatly reducing the strength of its action by 
first exhausting it with strong alcohol. 

Fluidextr. Senn,e (U. S. P.) is made in this manner. Dose, 
2 c.c. = 30 til. 

The stools occur about five to twelve hours after its adminis- 
tration. 



MATERIA MEDICA 457 

The best preparation is an extemporaneous infusion. This 
must not be boiled very long, else the activity suffers. 

The following are officinal: 

Infusum (Mistura, B. P.) Senn^e Compositum (U. S. P., 
B. P.) (Black Draught) .—Dose, 120 c.c. = 4 oz., U. S. P. An ex- 
cellent preparation. 

Contains per cent : Senna, 6 ; Manna, 12 ; Magnesium Sulphate, 
12 ; Fennel, 2. 

Pulvis GtLYCYrrhiz^ Compositus (U. S. P., B. P. ; Compound 
Licorice Powder). — Dose, 2 to 8 grams (J to 2 drams), stirred in 
water (4 grams = 1 oz., U. S. P). 

Contains per cent: Senna, 18; Sulphur, 8; and Glycyrrhiza, 
Oil of Fennel, and Sugar. 

Confectio Senn^ (U. S. P., B. P.). — Contains per cent: 
Senna, 10 ; Cassia Fistula, 16 ; Tamarind, Prune, and Coriander. 
Dose, 4 to 8 grams (1 to 2 drams). (4 grams = 60 grains, 
U. S. P.) 

Silver. — Silver is one of the most toxic metals for bacteria and 
protozoa, but is comparatively innocuous for the mammalian or- 
ganism. The salts have a great affinity for proteids, and are 
therefore astringent, irritant, or caustic, according to the strength 
in which they are used. This combination of astringent, caustic, 
and antiseptic actions, and the ease with which the effect may be 
graduated, make the silver salts, particularly the nitrate, very 
valuable. The lactate has recently been introduced under the 
name of ' ' actol, ' 7 but seems to possess no advantage. The citrate 
(also known as " itrol ") may be used sparingly as a dusting 
powder, since it is so little soluble (requiring 4,000 parts of water) 
that it cannot become caustic. 

The ordinary silver salts do not penetrate very deeply, since 
they are precipitated by proteids and chlorids. The addition of 
diethylendiamin to silver phosphate prevents this precipitation. 
This compound (Argentamin) is therefore more penetrating. It 
is marketed as a fluid containing as much Ag as a ten-per-cent 
silver-nitrate solution, and is used in corresponding strengths. 

The precipitation can also be avoided by combining the silver 
with proteids. The resulting products usually dissolve slowly in 
cold water. The solutions decompose on exposure to light. A 
number of these products are on the market, such as Argyrol (with 



458 MATERIA MEDICA 

vitellin, 20 to 25 per cent Ag.) ; Argonin (with casein, 4 per cent 
Ag.) ; Protargol (with albumose, 8 per cent Ag.) ; Largin (with 
protalbin, 11 per cent Ag.). The compounds retain the bac- 
tericidal properties of silver, but are practically nonastringent and 
nonirritant. The absence of these qualities may be desirable in 
some cases, while it is a serious drawback in others. They are 
used in gonorrhea ( T V to 2 per cent), conjunctivitis (0.5 to 5 per 
cent), nose and throat infections (2 to 10 per cent), etc. 

Colloidal Silver (" Collar golum ") is also permanently solu- 
ble in albuminous fluids, but is rendered insoluble by excessive 
quantities of salts. It is claimed to possess a peculiar value, since 
it is itself inert and harmless, and remains so in contact with 
normal tissues, while bacteria transform it into the active ionic 
form. It should therefore act automatically. It has been used 
locally like the ordinary silver salts; subcutaneously, in 0.5-per- 
cent solution for tuberculous joints; and systematically, for septi- 
cemia. For the latter purpose it may be given by mouth (pills 
of 0.01 gram) ; by inunction, 3 grams of Unguentum Crede (15 
per cent per day) ; or intravenously (10 c.c. of 0.5 per cent). 
(Sollmann.) 

Sodium (Natrum, Na). — The alkali metal sodium forms the 
greatest number of official compounds of any element. The series 
of compounds or salts are analogous to those of the other alkali 
metals, potassium, lithium, and ammonium. Like these, sodium 
compounds are all very soluble in water, the borate (borax) being 
the least soluble, requiring 20 parts water for solution, though 
none are deliquescent. They are, as a rule, insoluble in alcohol and 
other liquids, except that the bromid, iodid, and salicylate are 
fairly soluble in alcohol. The alkalies are represented by the hy- 
droxid, carbonate, and bicarbonate, their relative strength being 
in the order named. 

Soda cum Calce (N. F.; London Paste), a paste of equal parts 
of Sodium Hydroxid and Lime. 

Sodii Bicarbonas (Acid Sodium Carbonate, Baking Soda; 
NaHC0 3 ), white powder, soluble in 12 parts water, decomposed in 
boiling water. 

Uses: Antacid, alterative, antipruritic. The most convenient 
alkali base to form extemporaneously salts with the organic acids 
as illustrated in the following: 100 parts sodium bicarbonate re- 



MATERIA MEDICA 459 

quire for saturation or neutralization, in 25 fluid drams (100 c.c.) 
water, the stated number of parts of these respective acids and 
produce the parts named of the respective salts: 

Acid Benzoic, 144 parts = Sodium Benzoate, 170 parts. 

Acid Citric, 83 parts = Sodium Citrate, 140 parts. 

Acid Salicylic, 162.5 parts = Sodium Salicylate, 188.5 parts. 

Acid Tartaric 88.8 parts = Sodium Tartrate, 135.5 parts. 

Sodii Bisulphis. — Acid Sodium Sulphite; NaHS0 3 . 

Sodii Boras (Borax), transparent prisms, or white powder, 
soluble in 20 parts water, in 1 part glycerin; the solution in glyc- 
erin reacts and forms boroglycerid, with evolution of gas. 

Dose: 0.5 gram (7-§ grains). 

An antiseptic astringent powder for vaginal injection is pre- 
pared as follows: 

T$ Sodii boratis §ij 60 grams. 

Aluminis exsiccati ox 40 

Thymolis 

Phenolis 

Eucalyptolis 

Olei gaultheriae aa gr. vii j 5 ' ' 

M. Sig. : A heaping teaspoonful to be dissolved in 1 liter (1 
quart) of hot water, to be used as a douche. 

When it is desired to use sodium borate with boric acid, the fol- 
lowing will be found satisfactory: 

^ Acidi borici gr. xv 1 grams. 

Sodii boratis gr. xxx 2 ' ' 

Aquse dest. 

Aquae camphoraa aa Jiss 50 c.c. 

M. et ft. sol. Sig. : For instillation in the eye. 

Sodii Bromidum (Sodium Bromid; NaBr), cubical crystals, or 
white granular powder, soluble in 1.7 parts water, in 12.5 parts 
alcohol. 

Dose: 1 gram (15 grains). 

Sodii Carbonas Monohydratus. — Sodium carbonate contain- 
ing only one molecule water of crystallization, and therefore nearly 
twice as strong as the ordinary carbonate. 



460 MATERIA MEDICA 

Sodii Chloridum (Salt; NaCl). — Soluble in 2.8 parts water, 
in 25 parts boiling water. 

Uses : For preparing physiologic salt solution : 9 grams to 1,000 
c.c. sterile water ; not to be confused with the chemical normal solu- 
tion of NaCl. 

Dose: As emetic, 16 grams (240 grains). 

Sodii Citras (Sodium citrate), white, granular powder, soluble 
in 1.1 parts water, in 0.4 part boiling water; slightly soluble in 
alcohol. 

Dose: 1 gram (15 grains). 

Sodii Hypophosphis (Sodium Hypophosphite) , small plates, or 
white, granular powder ; very deliquescent ; soluble in 1 part water. 

Dose: 1 gram (15 grains). 

Syrupus Hypophosphitum, U. S. P. — Dose, 8 c.c. (2 fluid 
drams) . 

Syrapus Hypophosphitum Compositus, U. S. P. — Dose, 8 c.c. 
(2 fluid drams). 

Sodii Phosphas (Di-sodium-ortho-phosphate) , colorless prisms, 
or granular crystalline salt; soluble in 5.5 parts water; insoluble 
in alcohol. 

Dose: 0.25 gram (4 grains). 

Starch. — Amylum (Cornstarch), the starch grains obtained 
from the fruit of zea mays Linne (fam. Graminacea 3 ). 

In fine powder of irregular, angular white masses, consisting 
of somewhat spherical, but usually polygonal, grains, about 0.010 
to 0.025 mm. in diameter, with a lenticular, circular, or triangular 
central fissure; inodorous and tasteless; insoluble in cold water 
or alcohol; forming a whitish jelly when boiled with water, which, 
when cool, gives a deep blue color with iodin T. S. ; triturated with 
cold water, showing neither acid nor alkaline reaction with litmus 
paper; when completely incinerated, leaving not more that one 
per cent of ash. 

When freed from water by careful drying in a current of warm 
air, starch should show not less than ninety-five per cent of hy- 
drolyzable carbohydrate. (U. S. P.) 

Stramonium. — Leaves of Datura Stramonium. 

Dose: 0.065 gram, or 1 grain. 

Fluidextractum Stramonii, U. S. P. — Dose, 0.05 c.c. (1 TTl). 

Extractum Stramonii, U. S. P. — Dose, 0.01 gram (| grain). 



MATERIA MEDICA 461 

Tinctura Stramonii, U. S. P. — Dose, 1 c.c. (15 1TL). 

Unguentum Stramonii, U. S. P. — (Ten per cent extract.) 

Strychnin (Strychnina; C 21 H 22 N 2 2 = 331.73), alkaloid from 
nux vomica. Colorless, transparent, odorless, intensely bitter crys- 
tals, or white powder. Soluble in 6,400 parts water, 110 alcohol, 
5,500 ether, 6 chloroform. Excito-motor, nervine, stomachic, car- 
diac stimulant. Average dose: -^ grain (0.001 gram) in pills or 
tablets. Antidote: tannin; emetics: chloral hydrate, chloroform, 
or nicotin. 

The drug increases the irritability of the reflex arcs, beginning 
in the spinal cord and working upward; therefore a dose strong 
enough to affect the brain would begin to give almost a convulsive 
effect in the spinal centers. 

The drug has a local effect as a bitter tonic when taken by the 
mouth. This makes it particularly useful in wasting diseases, but 
it is questionable whether strychnin (the active principle) is as 
useful as the crude drug in such a condition. Strychnin is rapidly 
absorbed and is excreted by the sweat, saliva, bile, and especially 
urine. This excretion begins very soon after absorption, but lasts 
from two to eight days. The drug is unchanged in the body. 

In general, strychnin may be said to intensify the ordinary im- 
pulses, and it therefore is not a cardiac stimulant, strictly speak- 
ing, but rather a drug that brings about a general stimulation not 
only of the respiration and circulation, but also of all other bodily 
movements. 

In cases of poisoning from strychnin where a stage of tetanus 
or opisthotonos has been reached, chloroform is perhaps the best 
antidote. 

Preparations. — Tincture of nux vomica, ten-per-cent solution, 
used in 0.3- to 1.2-c.c. doses. Strychnin sulphate, used in 1-milli- 
gram (0.001 to 0.005 doses) dose, to be repeated in four hours if 
necessary. Brucin has more effect on the intestinal canal and a 
weaker effect on the spinal cord. It is therefore a very good 
stimulant for indigestion and for use in children. The dose varies 
from 0.005 to 0.03. 

Toxicity of Brucin and Strychnin. — Drs. W. E. Dixon and W. 
H. Harvey (Br. Phar. Conf., through Bull. Phar.) find by ex- 
periments that brucin is about one eighth as toxic as strychnin, but 
that the two alkaloids have a very different action. Strychnin 



462 MATERIA MEDICA 

acts on the sensory cells of the spinal cord and causes death by 
asphyxia, the muscles of the chest being locked in convulsions. 
Brucin causes slight convulsions at first, but this effect passes 
quickly, and the alkaloid then acts as a narcotic, paralyzing all the 
motor nerves. 

Stypticin. — Cotarnin (from opium) has been put on the market 
under the name of stypticin. It is cotarnin hydrochlorid ; C 12 H 13 - 
N0 3 H 2 0.HC1. Yellow, very bitter, hygroscopic powder. Soluble 
in water or alcohol. Dose : in habitual menorrhagia, f to 1J grains 
four or five times daily; in violent hemorrhage, 1J to 4 grains 
hypodermically. 

Another salt is called styptol, which is a neutral phthalate of 
cotarnin. This has a narcotic action, but no strychnin effect. It 
lowers the blood pressure by depressing the vasomotors. Its use 
is therefore indicated in capillary hemorrhage. 

Sulphonal, Trional, and Tetronal.— (CH 3 ) 2 C(S0 2 C 2 H 5 ) 2 = Sul- 
phonal (Sidphonmethanum) . 

CH 3 C 2 H 5 C(S0 2 C 2 H 5 ) 2 = Trional (Sulphonethylmethanum). 

(C 2 H 5 ) 2 C. (SO~C 2 H 5 ) 2 = Tetronal. 

These three resemble each other very closely in their action. 
Since trional is the more soluble, more quickly absorbed, and more 
active, it is now preferred. 

They are less dangerous than chloral, but do not act as strongly 
on pain, and if used for the latter must be supplemented by mor- 
phin. (Kast, 1888.) 

Their excretion seems to be slower than their absorption, so 
that there is a tendency to a cumulative action. This leads to 
gastritis, renal disease, and ill-understood changes in the blood, re- 
sulting in hematoporphyrinuria. The latter has so far been pro- 
duced only in man and rabbits. These phenomena can be avoided 
by intermitting the administration at times. The factor urea — 
nitrogen is lessened. The fate of sulphonal in the organism is 
not known. 

Sulphonal habit has been reported. 

Quite a number of fatal cases of acute sulphonal poisoning are 
on record. The prominent symptoms were: Various forms of 
paralysis, often of wide extent, rarely spasms; various cutaneous 
eruptions; gastrointestinal disturbance and extreme constipation; 
cardia and respiratory weakness, with a peculiar dyspnea; som- 



MATERIA MEDICA 463 

nolence or insomnia, frequently with mental disorder. Hemato- 
porphyrinuria is not always seen in acute eases. The autopsy is 
generally negative. (Taylor and Sailer, 1900.) 

Sulphonmethanum (U. S. P.; Sulphonal, B. P.), colorless 
crystals, odorless and tasteless. Soluble in 360 water, 47 alcohol, 
15 boiling water. Dose, to 2 grams (30 grains). (1 gram = 15 
grains, U. S. P.) Best as powders. 

Sulphonethylmethanum (U. S. P.; Trional) , colorless, odor- 
less crystals, bitter taste. Soluble in 195 water, more readily in 
boiling water, readily in alcohol. Dose, as preceding. 

Tetronal. — Properties and dose resembling the preceding. 

Sulphur. — Calx Sulphurata (Sulphurated Lime, improperly 
called " calcium sulphid "), mixture of sixty per cent Calcium 
Sulphid with Calcium Sulphate and Carbon. 

Grayish-white powder, decomposing by liberation of hydrogen 
sulphid when exposed to moist air; slightly soluble in cold water, 
readily in boiling water, which decomposes it. 

Dose: 0.065 gram (1 grain), in powder or capsule; should not 
be massed or formed in pills. 

Sulphur Lotum (Washed Sulphur.) — Uses: Alterative, laxa- 
tive, antiparasitic. Dose, 4 grams (60 grains). 

Pulveris GlyrrhizyE Compositus, U. S. P. — Dose, 4 grams (60 
grains) . 

Unguentum Sulphuris, U. S. P. — (Fifteen per cent.) 

Acidum Sulphuricum Dilutum (Diluted Sulphuric Acid). — 
Ten per cent ; H 2 S04. Uses : Tonic, astringent, and refrigerant ; to 
dissolve quinin and other alkaloids. 

Dose: 2 c.c. (30 TT\,), diluted. 

Syrup of Orange (Syrupus Aurantii, Syrup Aurantii Corticis). 
— Prepared from the tincture of fresh orange peel; this is a most 
exquisite flavored vehicle. 

Uses: As addition to liquid mixtures of various salts, that is, 
bromids, iodids, etc., about 25 c.c. (6 fluid drams) to a 100-c.c. (25 
fluid drams) mixture. 

Talc (Talcum Purificatum) . 

Talc, in fine powder 500 grams. 

Hydrochloric Acid 75 c.c. 

Water, a sufficient quantity. 
31 



464 MATERIA MEDICA 

Mix the powdered talc with about 2,500 c.c. of boiling water, 
gradually add 50 c.c. of the hydrochloric acid, and boil the mix- 
ture during fifteen minutes; then allow it to stand for fifteen 
minutes. Decant, and reject the supernatant liquid containing the 
finer particles of talc in suspension, and again boil the residue with 
2,500 c.c. of water, mixed with the remainder of hydrochloric acid, 
and allow it to stand for fifteen minutes. Again decant, and re- 
ject the finer suspended particles, and wash the coarser residue 
with water by repeated decantation, until a portion of the wash- 
water, after filtering and acidifying with nitric acid, fails to be- 
come opalescent upon the addition of silver-nitrate test solution, 
then transfer the magma to a close linen or muslin strainer, allow 
it to drain, and dry it at 110° C. (230° P.). 

Tannin (Acidum Tannicum, Gallotannic Acid; HC 14 H 9 9 ). — 
Very soluble in alcohol and water, cold or hot; in glycerin; almost 
insoluble in ether, chloroform, benzine, or petroleum benzine. It 
is prone to darken on exposure. Astringent and styptic. Used 
locally in hemorrhages, pure; in one- to ten-per-cent solutions as 
mouth washes, injections, lotions, collodion, etc. Average dose, 1\ 
grains (0.5 gram). Incompatible with salts of antimony, copper, 
iron, lead, mercury, and silver; with alkaloids, albumin, gelatin, 
iodin, iodoform; with permanganates, chlorates, and other ox- 
idizers; spirit nitrous ether. 

Tannin precipitates proteids, connective tissues, etc., by local 
contact. In this contact, albuminates are formed and an irritant 
acid quite similar to that formed by the mineral caustics is 
liberated. 

Tannin is very slowly absorbed from the intestinal canal. A 
small part of that which is absorbed is excreted by the urine. The 
major part of the tannin introduced into the intestinal canal is 
broken up into gallic acid, which is not astringent. Because of its 
astringent effect, small doses of tannic acid have some tonic action 
upon the bowel. Large doses, however, lead to gastroenteritis. 

It perhaps is the best drug for the treatment of diarrhea, it 
being valuable even in cases of cholera. To be most effective, tan- 
nin should, however « not act until it reaches the intestine, there- 
fore it should be given, if possible, in some form which passes 
through the acid contents of the stomach without decomposition. 
Such preparations may be obtained from natural drugs in the form 



MATERIA MEDICA 465 

of the tincture of gambir, or the tincture of kino, or krameria, any 
one of which is to be used in dosage of one half to one teaspoonful. 
Similar effects have been produced by artificial combinations; for 
instance, Tannalbin (Tannin Albuminate Exsiccated). 

Tannalbin contains fifty per cent of tannic acid, insoluble in 
ordinary solvents. Intestinal astringent. It is not acted upon at 
all in the stomach, but readily decomposed in the intestine, where 
it produces its local astringent action. 

Tannopin (Hexamethylenetetraminetannin; (CH 2 ) 6 N 4 , (C 14 - 
H 10 O 9 ) 3 = 1,098.16), a fawn-colored, odorless, tasteless powder. 
Eighty-seven per cent tannic acid and thirteen per cent urotropin 
(Hexamethylenamin). Insoluble in usual solvents decomposed by 
alkalies. Intestinal astringent and disinfectant. Dose, 10 to 15 
grains (0.65 to 1 gram) four times daily. 

This is insoluble, but liberates the tannin and the formaldehyd 
in the intestine. It is therefore recommended for septic diarrhea, 
but is of no value as an intestinal or urinary antiseptic. (Soll- 
mann, Journal of the American Medical Association, September 5, 
1908.) 

It is used also as a dusting powder. 

Tannoform (Tannin- formaldehyd; C 29 H 20 O 18 = 651.23), a 
condensation product of tannic acid and formaldehyd. Whitish- 
red, odorless powder. Soluble in alcohol, ammonia, alkalies; in- 
soluble in water. Drying antiseptic and deodorant, intestinal as- 
tringent and disinfectant. Dose, 4 to 15 grains (0.25 to 1 gram). 

This is a similar preparation to tannopin, but, since it is irri- 
tant, it can be used only for external application. 

Tannigen (Acetyltannin, Tannic Acid Acetic Ester), a light 
gray, nearly odorless and tasteless, slightly hygroscopic powder. 
Soluble in alcohol ; insoluble in water. Intestinal astringent. Dose, 
7 \ to 15 grains (0.5 to 1 gram), three to five times daily. This 
compound has proven quite satisfactory in the East. The dosage 
for a child should vary from 0.3 to 0.5. 

Collodion Stypticum is a combination containing twenty per 
cent tannin and eighty per cent collodion. 

Unguentum Acidi Tannici. — This is a twenty-per-cent oint- 
ment of tannic acid in benzoinated lard. 

GtLyceritum Acidi Tannici contains twenty per cent tannic acid. 
This is used externally as an astringent paint ; rarely internally. 



466 MATERIA MEDICA 

For rectal irrigation, etc., the ten-per-cent solution of tannin 
may be used, but for repeated colonic irrigations, as in bacillary 
dysentery, a two-per-cent solution seems sufficient. 

Tars. — Pix Liquida (U. S. P., B. P.; Pix Carbonis Preparata, 
B. P. ; Pine Tar) , an aromatic oleoresin obtained by the destructive 
distillation of pine woods, particularly that of Pinus palustris, 
conifera?, United States. Dose, 0.5 gram = 7J grains (U. S. P.). 
Soluble in alcohol or oils; only partly in water. Tar consists of 
a mixture of resinous and volatile principles. When it is sub- 
jected to redistillation, it can be separated into a fixed portion — 
pitch — consisting mainly of rosin; and a volatile portion, which 
separates into Oil of Tar (Oleum Picis Liquids, U. S. P.) and 
pyroligneous (crude acetic) acid. The oil of tar consists of various 
coal-tar derivatives, mainly Cresols, Guaiacol, Phenol, Xylol, Tol- 
uol, and Pyrocatechin. It also contains methyl alcohol and ace- 
tone. Dose, 0.2 c.c. = 3 ni (U. S. P.). 

Tar is used externally as antiseptic, parasiticide, and counter- 
irritant, in the form of: 

TJnguentum Picis Liquidce (U. S. P., B. P.). — Fifty per cent, in 
yellow wax and lard. 

Internally, it is used in bronchitis, like creosote; and as an ex- 
pectorant, most usefully as : 

Syrupus Picis Liquidce (U. S. P.). — Dose, 4 to 15 c.c. (1 to 4 
drams) . 

Theobromine Preparations : 

Diuretin. — We have already spoken of this drug under the head 
of caffein. It is chemically theobromin sodio-salicylate and con- 
tains fifty per cent theobromin. The dose is one gram in solution 
three times a day. It is well used in the form of a prescription 
written by Professor Eichhorst: 

^ Fol. Digitalis, Pulv 0.1 grams. 

Diuretini 1.0 " 

Sacch. Lactis 0.3 

M. f. chart, no. I. Da tales doses no. decern. S. : Take one 
powder in water three times a day. 

The difficulty with this prescription is that unless diuretin be 
used immediately it decomposes. Therefore only a small number 



MATERIA MEDICA 467 

of powders should be ordered. It would be preferable if the drug 
could be used iu solution, but its solubility seems to vary according 
to the condition in which the druggist has kept his stock. In 
other words, diuretin decomposes so readily that only fresh prod- 
ucts should be used. With the fresh drug solutions in peppermint 
water might be used, e. g. : 

^ Diuretini 10.0 grams. 

Aquae menthae piperita? 100.0 c.c. 

M. D. S. : One dessertspoonful t. i. d. 

Agurin. — Theobromine sodio-acetas. C 7 H 7 NaN 4 2 . NaC 2 - 
H 3 2 = 282.19. AVhite, hygroscopic, alkaline powder. Soluble 
freely in water; decomposed by acids. Diuretic, without effect on 
heart. Dose, 5 to 15 grains (0.3 to 1 gram). 

Agurin contains 63.6 per cent of theobromin. In my hands it 
has been less effective than diuretin. 

Theocin. — Theophyllin; dimethylxanthin, C 7 H s N 4 2 . White, 
odorless, bitter powder. Soluble in 180 parts water; forms salts 
with alkalies. Diuretic. Dose, 3 to 5 grains (0.2 to 0.3 gram). 
This costs more than diuretin and agurin, and is practically in- 
soluble. On the other hand, the doses are smaller. 

Thiosinamin (Thiosinamina, Allyl Sulphocarbamid, Allyl Thi- 
ourea, Rlwdallin; (NH 2 ) . CS . NHCH 2 CH : 2 CH = C 4 H 8 N 2 S) is a 
condensation product of allyl thiocyanate and ammonia. 

It is prepared by warming together volatile oil of mustard 
(chiefly allyl thiocyanate) and alcoholic solution of ammonia, col- 
lecting the crystalline product of condensation, and recrystallizing 
from alcohol. 

It forms colorless crystals, having a slight alliaceous odor and 
bitter taste and melting at 74° C. (165.2° F.). It is moderately 
soluble in water, but is decomposed by this solvent. It is soluble 
in about 3 parts of alcohol and readily soluble in ether. 

It is incompatible with water, which decomposes it, but this 
change is, to a limited extent, prevented by the presence of 
glycerin. 

Thiosinamin appears to cause or quicken the absorption of exu- 
dates, lymphatic swellings, scar tissue, etc., the action being unex- 
plained. The opinions as to its value are contradictory. 



468 MATERIA MEDICA 

It is used by hypodermic injection in lupus, chronic glandular 
tumors, cicatrices, etc. By the mouth in stricture, corneal opacity, 
chronic deafness. 

Dose : 0.3 to 0.1 gram (J to 1-J grains) , in capsules or tablet 
triturates; in subcutaneous injections, 0.05 to 0.2 gram (1 to 5 
grains), in fifteen-per-cent alcoholic or ten-per-cent glycerinated 
water solution. (N. N. R.) 

Thymol (U. S. P., B. P.; C 6 H 3 (CH 3 ) (OH) (C 3 H 7 ) 1:3:4:), a 
phenol (stereoptene) occurring in the volatile oil of Thymus vul- 
garis, Carum Ajowan, and some others. Large, colorless crystals 
of peculiar odor. Liquefies when triturated with camphor, menthol, 
or chloral. Soluble in 1,100 water, freely in alcohol. Dose, 0.05 
to 1 gram (1 to 15 grains). 

Liquor Antisepticus (U. S. P.), a mild antiseptic, containing 
in 1,000: 20, Boric acid; 1, Benzoic acid; 1, Thymol; 0.25, Eu- 
calyptol; 0.5, Oil Peppermint; 0.25, Oil Gaultheria; 0.1, Oil Thyme; 
250, Alcohol. A number of proprietary mixtures, e. g., ' ' listerine, ' ' 
have a similar composition. 

Thyroid Extract {Glandulce Thyroidece Siccce, Desiccated Thy- 
roid Glands) , the thyroid glands of the sheep (Ovis aries Linne), 
freed from fat, and cleaned, dried, and powdered. 

A yellowish, amorphous powder, having a slight, peculiar odor, 
and containing the active ingredient of the thyroid tissue ; partially 
soluble in water. 

One part of Desiccated Thyroid Glands represents approxi- 
mately 5 parts of the fresh glands. (U. S. P.) 

Tohi. — Balsamum Tolutanum (U. S. P., B. P.). — Its prepara- 
tions are very popular as vehicles in cough mixtures, etc. It is a 
solid balsam, derived from Toluifera Balsamum, Leguminosae; 
Venezuela. It is used as: 

Syrupus Tolutanus (U. S. P., B. P.). — Dose, ad libitum. 

Tinctura Tolutana (U. S. P., B. P.). — Twenty per cent. 
Dose, 2 to 4 c.c. (-| to 1 dram). 

Acidum Trichloracetum (Trichloracetic Acid), white, deliques- 
cent crystals, very soluble in alcohol or ether. 

Uses: Chiefly as a chemical reagent; astringent, escharotic, 
hemostatic; to remove warts and other skin blemishes, in ten-per- 
cent water solution ; astringent or hemostatic, one- to three-per-cent 
solution ; must be used with care. 



MATERIA MEDICA 469 

Oil of Turpentine (Oleum Terebinthince Rectificatum) . — For 
medicinal use. Anthelmintic, diuretic, antiseptic. Used in dysen- 
tery, whooping cough, retention of urine, tapeworm, phosphorus 
poisoning, etc. Average dose, 15 TT\, (1 c.c.) ; in tapeworm, 1 to 2 
fluid drams (4 to 8 c.c). 

The oil of turpentine is insoluble in water, but soluble in 3 
parts of alcohol. It is used as a liniment, which, if covered by an 
impermeable bandage, produces a blister. It is excellent for use 
in bronchitis, either as an oil spray or in a vapor with steam. In 
this connection it should be noted that it has a tendency to stimu- 
late the bronchial mucous membrane to throw off the accumula- 
tion of exudates. In this way it may cause a paroxysm of cough- 
ing, and in weak patients, on this account, it may have to be 
avoided. In chronic cases, if used in the form of the turpentine 
pipe, it will prove very effective. 

It has a considerable reputation as an anthelmintic, and for 
such purpose should be given in the morning before breakfast in 
doses of five drops each at fifteen-minute intervals, to be followed 
by an active purge. The drug should, of course, not be adminis- 
tered to patients with diseased kidneys. 

Its general action is that of phenol or camphor. Applied to the 
skin, it penetrates deeply and irritates. This irritation is followed 
Ijy a paralysis of the sensory nerves. Because of this paralysis, it 
may appear to give relief in boils and bruises and similar irritative 
conditions, as soon as the preliminary burning is over. The maxi- 
mum dosage of the rectified spirits (or oil) is 1 c.c. 

Linimentum Terebinthin^ consists of 1 part turpentine to 2 
parts rosin cerate. 

Urea, CO(NH 2 ) 2 = CH 4 ON 2 , is the diamid of carbonic acid. 

Urea occurs as colorless, transparent prismatic crystals, almost 
odorless, having a cooling, saline taste. It is somewhat hygroscopic. 
It is soluble in water (1-1), more readily in hot water. Soluble in 
alcohol (1-7) and (1-1) in boiling alcohol. It is insoluble in ether 
and chloroform. 

Urea is an active diuretic; it is rapidly eliminated and is not 
poisonous. It has been claimed, without convincing proof, to have 
the power of dissolving urinary calculi. It has been recommended 
in the treatment of tuberculosis, but this use of it is generally aban- 



470 MATERIA MEDICA 

cloned. It may be employed where diuresis is indicated, though it 
appears irrational in primary renal disease. 

Dose, 0.5 to 4 grams (10 to 60 grains). Urea is given in solu- 
tion, or it may be inclosed in cachets. (N. N. R.) 

Valerian. — The name valerian is said to come from that of 
Valerius, the man who first introduced it into medicine. The rhi- 
zome and roots of the plant are used, and they contain one to two 
per cent of volatile oil with valerianic and other acids, tannin, and 
resin. The oil develops the medicinal properties while the plant 
is dried or drying, only to lose this property if kept too long. 

The fluid extract is three fourths alcohol. Dose, 2 c.c. (30 TT^). 

The tincture is twenty per cent. Dose, 5 c.c. 

The Ammoniated Tincture is also thirty per cent, the rest being 
the aromatic spirits of ammonia. Dose, same ; well diluted. 

Valyl (Diethylamid of Valerianic Acid), a colorless liquid of 
peculiar odor and burning taste, is marketed in capsules which do 
not dissolve in the stomach (to avoid causing the patient to belch), 
and which contain 0.125 gram (2 grains). The dose is two to three 
of these " pearls " three times a day. This preparation is there- 
fore intended more for the hysteria and general nervousness than 
for the local condition. 

Veratrum Viride (American Hellebore, Green Hellebore, Amer- 
ican Yeratrum, Indian Vote), the dried rhizome and roots of vera- 
trum viride, liliacse. North America. Contains jervin, pseudo- 
jervin, veratrin (cevadin), rubijervin, veratralbin, veratroiodin, 
resin, and starch. Because of having such a complex constitution 
its physiological action is very complex and variable. It retards 
the heart's action and softens the pulse. The dose of the fluid ex- 
tract is one to three drops. 

Veronal (Diethyl-malonyl-urea) has been highly recommended. 
It is a white, crystalline powder of faintly bitter taste. Soluble in 
150 water. Dose, 0.3 to 1 gram (5 to 15 grains), in capsule or in 
hot milk. Habit has been reported. (Krep, 1905.) 

Waters (Mineral Waters). — In order that the reader may be 
able to utilize the more available American waters where our text- 
books have directed the use of European waters, we give below 
some general analyses, both of the European and American waters. 



MATERIA MEDICA 471 

Thus the artificial Kissingen water is made up as follows 

(N. F.) : 

Potassium Chlorid 17 

Sodium Chlorid 337 

Magnesium Sulphate 59 

Sodium Bicarbonate 107 

(24 grains of this to 6 ounces of water is the usual proportion.) 

We secure a similar water when we prescribe the White Rock 
and other light American table waters. Kissingen is regarded as 
a plain saline water, but of the plain salines ocean water is, of 
course, the type. Of this 1,000 parts contain : 

NaCl 27.0 

KC1 0.75 

MgCl 2 3.7 

MgBr 0.027 

MgS0 4 2.3 

CaS0 4 1.4 

CaC0 3 0.02 

Iodids, etc Traces. 

Artificial sea baths may be made by dissolving four per cent of 
sea or rock salt in water. 

Vichy, according to the National Formulary, contains: 

Sodium Bicarbonate 846.0 

Potassium Carbonate 38.5 

Magnesium Sulphate 38.5 

Sodium Chlorid 77.0 

(14 grains to 6 ounces of water — ^ teaspoonful to the tumbler — 
is the usual proportion.) This is an alkaline saline water. 

Carlsbad is a carbonated saline water. The artificial salt is 
made as follows: 

K 2 S0 4 0.12 

Na 2 S0 4 2.64 

NaHCO s 2.16 

NaCl 1.08 

This equals a teaspoonful of the combined salts, and should be 
added to the liter of water. 



472 



MATERIA MEDICA 



Hunyadi Janos contains in 1,000 grams: 

MgS0 4 22.3 

Na 2 S0 4 22.5 

NaCl 1.3 

This water makes a strongly cathartic alkaline water, suitable for 
bad cases of constipation, especially if complicated with hyperacid- 
ity of the stomach. 

Seidlitz in 1,000 grams contains : 

MgS0 4 13.5 

CaS0 4 1.4 

MgCl 2 0.4 

Friedrichshall belongs to the same group. 

The following are representative American waters, and the 
analyses here given will enable the student to classify them with 
the European waters just named. 



Allouez Magnesia Water, Green Bay, Wis. : 



(Calcic bicarb onated alkaline) 

Parts per 
Formula and Name. million. 

NH 4 C1 (Ammonium Chlorid) 0.03 

LiCl (Lithium Chlorid) Trace 

KC1 (Potassium Chlorid) 3.2 

NaCl (Sodium Chlorid) 27.7 

MgCl 2 (Magnesium Chlorid) 17.1 

MgS0 4 (Magnesium Sulphate) 73.7 

Ca 3 (P0 4 ) 2 (Calcium Phosphate) ... . Trace 

NaN0 3 (Sodium Nitrate) 36.43 

Mg(HC0 3 ) 2 (Magnesium Bicarbo- 
nate) 145.1 

Ca(HC0 3 ) 2 (Calcium Bicarbonate). 317.8 

23 I (Ferric Oxid and Albumina) . 1.2 

CaSi0 3 (Calcium Silicate) 25.9 

Si0 2 (Silica) 7.7 

Total 655.86 



Per cent of 

total inorganic 

material in 

solution. 



0.49 

4.22 

2.61 

11.24 

5.55 

22.13 
48.46 

0.18 

3.95 
1.17 

100.00 



MATERIA MEDICA 



473 



Buffalo Lithia Water, Buffalo Lithia Springs, Va. : 



(Calcic Sulphated Saline) 



Formula and Name. 



Parts per 
million. 



NH 4 C1 (Ammonium Chlorid) 0.114 

LiCl (Lithium Chlorid) Trace 

KC1 (Potassium Chlorid) 7.6 

NaCl (Sodium Chlorid) 12.0 

NaS0 4 (Sodium Sulphate) 77.7 

MgS0 4 (Magnesium Sulphate) 31.7 

CaS0 4 (Calcium Sulphate) 463.8 

Ca 3 (P0 4 ) 2 (Calcium Phosphate) Heavy trace 

NaN0 2 (Sodium Nitrite) Trace 

NaN0 3 (Sodium Nitrate) 3.03 

Ca(HC0 3 ), (Calcium Bicarbonate). 112.6 

Fe O ) 

aiVi 3 \ ( Ferric Oxid an d Alumina) . 0.7 

A1 2 (J 3 ) 

CaSi0 3 (Calcium Silicate) 6.4 

Si0 2 (Silica) 31.6 

Total 747.244 



Per cent of 

total inorganic 

material in 

solution. 

0.02 



1.02 

1.61 

10.40 

4.24 

62.05 



0.41 
15.07 

0.09 

0.86 
4.23 

100.00 



The value of this water lies evidently not in its lithium content, 
but rather in the calcium and sulphates. 



474 



MATERIA MEDICA 



Congress Water, Saratoga, N. Y. : 



(Sodic muriated alkaline-saline, carbondioxated) 



Formula and Name. 



Parts per 
million. 



NH 4 C1 (Ammonium Chlorid) 30.64 

LiCl (Lithium Chlorid) 32.7 

KC1 (Potassium Chlorid) 340.5 

NaCl (Sodium Chlorid) 5,141.6 

KBr (Potassium Bromid) 40.0 

KI (Potassium Iodid) 1.0 

Na 2 S0 4 (Sodium Sulphate) 12.9 

NaB0 2 (Sodium Metaborate) . Small amount 

NaN0 2 (Sodium Nitrite) Trace 

Na(HCO s ) (Sodium Bicarbonate). 627.8 
Mg(HC0 3 ) 2 (Magnesium Bicarbon- 
ate 1,674.9 

Ca(HC0 3 ) 2 (Calcium Bicarbonate) 2,276.5 
Ba(HC0 3 ) 2 (Barium Bicarbonate) 13.4 
Sr(HC0 3 ) 2 (Strontium Bicarbon- 
ate) Trace 

Fe Oo ) 

23 v (Ferric Oxid and Alumina) 21.0 

•AI 2 3 ) 

Si6 2 (Silica) 19.8 

Total 10,232.74 



Per cent of 

total inorganic 

material in 

solution. 

0.30 

0.32 

3.33 

50.24 
0.39 
0.01 
0.12 



6.14 

16.38 

22.25 

0.13 



0.20 
0.19 

100.00 



MATERIA MEDICA 



475 



Hathorn Water, Saratoga, N. Y. : 



(Sodic muriated alkaline-saline, carbondioxated) 



Formula and Name. 



NH 4 C1 (Ammonium Chlorid) 

LiCl (Lithium Chlorid) 

KC1 (Potassium Chlorid) 

NaCl (Sodium Chlorid) 

KBr (Potassium Bromid) 

KI (Potassium Iodid) 

Na 2 S0 4 (Sodium Sulphate) 

NaB0 2 (Sodium Metaborate) . Small amount 

NaN0 2 (Sodium Nitrite) Trace 

Na(HC0 3 ) (Sodium Bicarbonate). 220.9 
Mg(HC0 3 ) 2 (Magnesium Bicarbon- 
ate 1,974.7 

Ca(HC0 3 ) 2 (Calcium Bicarbonate) 3,098.3 
Ba(HC0 3 ) 2 (Barium Bicarbonate) 14.2 
Sr(HC0 3 ) 2 (Strontium Bicarbon- 
ate) Trace 

aiV* 3 [ (ferric Oxid and Alumina) 9.6 

A1 2 (J 3 ) 

Si0 2 (Silica) 16.5 

Total .*... 13,170.39 



Parts per 
million. 


Per cent of 

total inorganic 

material in 

solution. 


37.80 


0.29 


44.9 


0.34 


332.5 


2.52 


,343.7 


55.76 


70.0 


0.53 


2.2 


0.02 


5.0 


0.04 



1.68 

14.99 

23.52 

0.11 



0.07 
0.13 

100.00 



476 



MATERIA MEDICA 



Manitou Table Water, Manitou, Col.: 



(Sodic and calcic bicarb onated alkaline carbondioxated) 



m at Parts per 

Formula and Name. .«. 

million. 

NH 4 C1 (Ammonium Chlorid) 0.15 

LiCl (Lithium Chlorid) 1.38 

KC1 (Potassium Chlorid) 136.10 

NaCl (Sodium Chlorid) 303,20 

KBr (Potassium Bromid) Faint trace 

Na 2 S0 4 (Sodium Sulphate) 324.20 

NaB0 2 (Sodium Metaborate) . Small amount 
Na(HCO s ) 2 (Sodium Bicarbonate). 1,193.20 
Mg(HC0 3 ) 2 (Magnesium Bicarbon- 
ate) 476.80 

Ca(HC0 3 ) 2 (Calcium Bicarbonate). 1,854.50 
Fe(HC0 3 ) 2 (Ferrous Bicarbonate) . 5.70 

Mn 3 4 (Mangano-manganic Oxid) . . 2.40 

Si0 2 (Silica) 47.2 

Total 4,344.83 



Per cent of 
total material. 



0.03 
3.13 

6.98 

7.46 

27.46 

10.97 

42.69 

.13 

.06 
1.09 

100.00 



MATERIA MEDICA 



477 



Mount Clemens Water, Mount Clemens, Mich.: 



Formula and Name. 



Parts per 
million. 



NHC1 (Ammonium Chlorid) 0.157 

LiCl (Lithium Chlorid) Trace 

KC1 (Potassium Chlorid) 6.5 

NaCl (Sodium Chlorid) 37.6 

KBr (Potassium Bromid) Trace 

KI (Potassium Iodid) Trace 

Na 2 S0 4 (Sodium Sulphate) 459.6 

MgS0 4 (Magnesium Sulphate) 291.5 

CaS0 4 (Calcium Sulphate) 1,618.7 

NaB0 2 (Sodium Metaborate) Small amount 

NaN0 3 (Sodium Nitrate) Trace 

NaN0 2 (Sodium Nitrite) .014 

Ca(HCO) (Calcium Bicarbonate) 197.0 

Fe(HC0 3 ) 2 (Ferrous Bicarbonate) ... 4.5 

Mn 3 4 (Mangano-manganic Oxid) .... Trace 

SiO (Silica) 27.6 

Total 2,643.171 



Per cent of 

total inorganic 

material in 

solution. 



0.25 
1.42 



17.39 
11.03 
61.25 



7.45 
.17 

1.04 
100.00 



In Japan the waters of such springs as the above — particularly 
when hot — are used freely by syphilitics. The government classifi- 
cation makes this a sodic muriated saline sulphureted water. 



478 MATERIA MEDICA 



Pagosa Spring, Colorado: 



Great Carlsbad 

(Sprudel 



Spring. Spring). 

Sodium Chlorid 13.380 15.450 

Sodium Carbonate 18.025 20.415 

Sodium Sulphate 32.730 35.580 

Calcium Carbonate 9.040 4.455 

Magnesium Carbonate 1.440 1.860 

Lithium Carbonate 0.710 

Potassium Carbonate 0.607 

Strontium Carbonate 0.012 

Iron Protoxid 0.036 0.030 

Manganese Protoxid 0.042 0.009 

Calcium Fluorid 0.066 0.045 

Calcium Phosphid 0.007 0.003 

Silica 0.155 0.108 

" Pagosa Springs, by quantitative analyses, is the nearest to the 
famous Carlsbad Sprudel Spring of anything found in the United 
States ; and it is owing to the similarity to these waters that Pagosa 
Springs can rightfully be called ' The Carlsbad of America.' " (Circular 
from the owners.) 



MATERIA MEDICA 



479 



Pluto Concentrated Water, French Lick, Ind. 
(Sodic sulphated saline) 



_ AT Parts per 

Formula and Name. .,,- 

LiCl (Lithium Chlorid) Heavy trace 

KC1 (Potassium Chlorid) 539.9 

NaCl (Sodium Chlorid) 1,960.9 

KI (Potassium Iodid) Trace 

MgS0 4 (Magnesium Sulphate) 30,195.8 

Na 2 S0 4 (Sodium Sulphate) 64,425.2 

CaS0 4 (Calcium Sulphate) . 1,095.8 

NaN0 2 (Sodium Nitrate) Trace 

Ca(HC0 3 ) 2 (Calcium Bicarbonate) .... 288.8 

FeO ) 

. 3 > (Ferric Oxid and Alumina).. . . 5.0 
A1 2 (J 3 ) 

Si0 2 (Silica) 29.2 

Total 98,540.6 



Per cent of 
total material. 



0.55 
1.99 

30.65 

65.38 

1.11 

.29 



.03 



100.00 



Red Raven Aperient Water, 



Formula and Name. 

NaCl (Sodium Chlorid) 

Na 2 S0 4 (Sodium Sulphate) 

Na 2 HP0 4 (Di-sodium Phosphate) 

Na(HCOg) (Sodium Bicarbonate) . . 
Si0 2 (Silica) 

Total 



armarville, 


Pa.: 


Parts per 


Per cent of 


million. 


total material, 


166.1 


0.60 


986.9 


3.55 


26,329.8 


94.40 


341.5 


1.22 


63.6 


.23 



100.00 



This water is supersaturated with carbon dioxid. 



480 MATERIA MEDICA 



Regent Spring Water, Excelsior Springs, Mo.: 

Grains per 
Name - U. S. Gallon. 

Alumina 0.1224 

Silica 0.6998 

Potassium Sulphate 0.2834 

Potassium Chlorid 0.1633 

Sodium Chlorid 1.0264 

Sodium Bicarbonate 0.5452 

Iron Bicarbonate 4.1934 

Manganese Bicarbonate 0.8445 

Magnesium Bicarbonate 5.5445 

Calcium Bicarbonate 34.2406 

47.6635 



Siloam Springs Water, Excelsior Springs, Mo.: 

Grains per 
Name - U. S. Gallon. 

Silica 1.6777 

Potassium Sulphate 0.1929 

Calcium Sulphate 1.3028 

Calcium Bicarbonate 21.5233 

Magnesium Bicarbonate 0.2524 

Manganese Bicarbonate 0.2524 

Iron Bicarbonate 2.7688 

Sodium Chlorid 0.9949 

Magnesium Chlorid 0.7540 

Alumina 0.3890 

32.2863 



MATERIA MEDICA 



481 



Sulphosaline Water, Excelsior Springs, Mo.: 

Grains per 
Name ' U. S. Gallon. 

Silica 0.5899 

Alumina 2.2780 

Ferrous Carbonate 0.0921 

Calcium Bicarbonate 17.9658 

Calcium Sulphate 32.1800 

Magnesium Sulphate 29.7400 

Potassium Chlorid 4.7300 

Sodium Chlorid 363.6535 

479.7793 



Veronica 



Formula and Name. 



Parts per 
million. 



NH 4 C1 (Ammonium Chlorid) 0.24 

KC1 (Potassium Chlorid) 169.5 

NaCl (Sodium Chlorid) 3,170.0 

KI (Potassium Iodid) Heavy trace 

Na 2 S0 4 (Sodium Sulphate) 802.7 

MgS0 4 (Magnesium Sulphate) 15,151.4 

CaS0 4 (Calcium Sulphate) 744.3 

Ca 3 (P0 4 ) 2 (Calcium Phosphate) Trace 

NaN0 3 (Sodium Nitrate) 2,384.9 

Ca(HC0 3 ) 2 (Calcium Bicarbonate) 1,397.8 

Fe O ) 

. 2 3 [ (Ferric Oxid and Alumina) 3.7 

Si0 2 (Silica) 18.1 

Total 22,842.64 



Per cent of 

total inorganic 

material in 

solution. 



0.74 

13.88 

3.51 

61.95 

3.26 

10.44 
6.12 

.02 

.08 

100.00 



This water is found at Santa Barbara, Cal., and is bottled 
without additions. It is a magnesic sulphated saline. 



482 



MATERIA MEDICA 



Vichy Water, Saratoga, N. Y. : 
(Sodic muriated alkaline-saline, carbondioxated) 



Formula and Name. 

NH 4 C1 (Ammonium Chlorid) 

LiCl (Lithium Chlorid) 

KC1 (Potassium Chlorid) 

NaCl (Sodium Chlorid) 

KBr (Potassium Bromid) 

KI (Potassium Iodid) 

Na 2 S0 4 (Sodium Sulphate) 

NaB0 2 (Sodium Metaborate) Small 

Na(HC0 3 ) (Sodium Bicarbonate) 

Mg(HC0 3 ) 2 (Magnesium Bicarbonate) . . 
Ca(HC0 3 S) 2 (Calcium Bicarbonate).... 

(Ferric Oxid and Alumina) 



ai 2 o 3 

CaSI0 3 (Calcium Silicate) 
Si0 2 (Silica) 



Parts per 
million. 



2.64 

.6 

7.4 

1,499.1 

Trace 

Trace 

29.9 

amount 

837.1 

60.8 

158.8 

3.2 

27.6 
1.9 



Per cent of 

total inorganic 

material in 

solution. 

0.10 

.02 

.28 

57.02 



1.14 

31.85 
2.31 

6.04 

.12 

1.05 
.07 



Total 2,629.04 



100.00 



MATERIA MBDICA 



483 



White Rock Lithia Water, Waukesha, Wis.: 

Per cent of 
Parts per total inorganic 
Formula and Name. million. material in 

solution. 

NH 4 C1 (Ammonium Chlorid) 0.125 0.01 

LiCl (Lithium Chlorid) 76.4 6.35 

KC1 (Potassium Chlorid) 5.7 .47 

NaCl (Sodium Chlorid) 573.6 47.65 

MgCl 2 (Magnesium Chlorid) 26.2 2.18 

MgS0 4 (Magnesium Sulphate) 49.6 4.12 

NaN0 2 (Sodium Nitrite) .024 

NaN0 3 (Sodium Nitrate) 6.07 .50 

Mg(HC0 3 ) 2 (Magnesium Bicarbonate) . . 125.2 10.41 

Ca(HC0 3 ) 2 (Calcium Bicarbonate) 327.7 27.23 

FeO ) 

3 [■ (Ferric Oxid and Alumina) .57 .05 

Si0 2 (Silica) 12.4 1.03 

Total 1,203.589 100.00 



This is a sodic and calcic muriated alkaline-saline carbondiox- 
ated water. 



484 MATERIA MEDICA 



Witter Springs Water 



Name. 



Grains per 
U. S. Gallon. 



Lithium Chlorid .018 

Potassium Chlorid 9.615 

Sodium Chlorid 55.216 

Sodium Sulphate .144 

Strontium Bicarbonate (with Spectroscope).. .Strong test 

Sodium Metaborate .058 

Magnesium Sulphate .501 

Calcium Phosphate .032 

Sodium Nitrate Trace 

Sodium Bicarbonate 579.258 

Barium Bicarbonate (with Spectroscope) Strong test 

Calcium Bicarbonate 34.928 

Magnesium Bicarbonate 333.030 

Ferrous Bicarbonate .778 

Manganese Bicarbonate .289 

Silica 488 

Carbonic Acid, Free 67.999 

Total 1,082.354 

The water is obtained from the Witter Medical Springs in Lake 
County, Cal., and is bottled directly from the springs without 
charging. 



MATERIA MEDICA 485 

Wool Fat: 

Adeps Lan,e (Wool Fat). — The purified fat of the wool of 
sheep (Ovis Linne) freed from water. 

A light yellowish, tenacious, unctuous mass, having a slight, 
peculiar odor. 

Insoluble in, but miscible with, large quantities of water, spar- 
ingly soluble in cold alcohol, more soluble in hot alcohol, readily 
soluble in ether and chloroform. 

Wool fat melts at about 40° C. (104° P.), and at a higher 
temperature vaporizes, the vapor igniting and burning with a 
luminous, sooty flame. 

Adeps Lan^e Hydrosus (Hydrous Wool Fat). — The purified fat 
of the wool of sheep (Ovis aries Linne), mixed with not more than 
thirty per cent of water. 

A yellowish-white, or nearly white, ointment-like mass, having 
a slight, peculiar odor. 

Insoluble in water, but miscible with twice its weight of the 
latter, without losing its ointment-like character. With ether or 
chloroform it yields turbid solutions which are neutral to mois- 
tened litmus paper. 

Hydrous wool fat melts at about 40° C. (104° F.), and sepa- 
rates into an upper oily and a lower aqueous layer. (U. S. P.) 

Yohimbin (C 22 H 28 N 2 3 HC1), an alkaloid isolated by Spiegel 
(1896) from the bark of the Yohimbehe tree (family of Apocy- 
naceas), growing in German West Africa. The local application 
one- to two-per-cent solution) produces the same anesthetic effect 
as cocain, and is less toxic. The effect begins in ten to fifteen 
minutes and lasts one half to one and three quarter hours. The 
vessels are rather dilated, even when adrenalin is added. In the 
eye, the anesthesia occurs more promptly (one half to one minute, 
lasting ten to fifteen minutes) . It should not be used in this organ, 
since it causes considerable irritation, lasting four to six hours. 
The pupils are dilated, the mydriasis lasting some twenty-four 
hours. Accommodation is but little affected. 

When it is given by the mouth or hypodermically in moderate 
doses it produces a general vaso-dilation in the skin, mucous mem- 
branes, and particularly in the sexual organs. In consequence 
of the latter, and perhaps by a direct action on the spinal centers, 



486 MATERIA MEDICA 

it produces erection. It does not seem to stimulate the production 
of spermatozoa or sexual desire. 

In consequence of this action on animals, the alkaloid has been 
used as an aphrodisiac in neuropathic impotence, apparently with 
fair success. The reports must be accepted with caution, consider- 
ing the possibility of psychic suggestion. The effect in animals 
occurs immediately ; that in man only after some four to six weeks. 
This makes it difficult to explain the clinical observations by the 
animal experiments. 

The continued administration of the alkaloid is said to lead to 
no bad effects; however, the resemblance of its action to that of 
cocain would suggest that it may perhaps create a habit. Ordi- 
nary doses produce a psychic excitement similar to that of cocain. 
(This has been referred to dilation of the cerebral vessels.) There 
is also some distention of the cerebral vessels and vertigo. Gastric 
disturbance has been noticed. The effects of larger doses also agree 
with those of cocain. Toxic doses cause general stimulation and 
subsequent paralysis of the nervous centers, particularly in the 
medulla. 

The free alkaloid and the solutions of the hypochlorid being 
unstable, the dry salt is marketed in the form of tablets, contain- 
ing 5 mg. ( T V gr.) ; three tablets per day are the ordinary dose. 
(Sollmann.) 

Zinc Compounds. — All the zinc compounds^ except the carbonate 
and oxid, are very soluble in water and are regarded as poi- 
sonous. Poison. — Antidotes: Alkaline carbonates, tannin, emetics, 
stimulants. 

Zinci Chloridum (Zinc Chlorid; ZnCl 2 ), white granular pow- 
der, or fused mass, so very deliquescent that the official solution 
should preferably be used by taking twice the weight required of 
the salt. 

Liquor Zinci Chloridi, U. S. P. — (Fifty per cent.) 

Caution. — Solutions for injection should not exceed 0.2 per cent 
in strength. 

Zinc Oxidum. — Zinc Oxid. — ZnO. 

White, fine amorphous powder, insoluble in water or alcohol. 

Unguentum Zinci Oxidi, U. S. P. — (Twenty per cent.) 



INDEX 



INDEX 



Aborting a cold, 113. 
Abrasions, 95. 
Abscess of liver, 228. 
Acetanilid, 22. 
Acetic acid, 396. 
Acetic ether, 423. 
Acetone chloroform, 413. 
Acetonum, 396. 
Acetphenetidin, 22. 
Acidosis, 356. 
Acidum aceticum, 396. 

boricum, 404. 

carbolicum, 446. 

citricum, 413. 

lacticum, 432. 

tannicum, 464. 

trichloracetum, 468. 
Aconite, 120, 396. 

in fever, 32. 
Actinomycosis, 365. 
Actol, 457. 
Adenitis, 339. 
Adiposa dolorosa, 63. 
Adolescence, heart in, 267. 
Adrenal bodies, 342. 
Adrenalin, 422. 

in shock, 58, 92. 
Adrenalin inhalant, 122. 
Age and dose, 392. 
Agurin, 467. 
Alcohol, as solvent, 14. 

for sciatica, 17. 
Alcoholic content of beverages, 393. 
Alcoholic solutions for itching, 37. 
Alkalies in arthritis, 348. 
Alkaline sprays, 115. 



Allouez water, 472. 

Aloe, 397. 

Alternating douche, 63. 

Alum, 397. 

Ameba coli, 242. 

Ammonium carbonate, 136, 380. 

Ammonium salts, 397. 

Ammonium sulpho-ichthyolate, 428. 

Amyl nitrite, 437. 

Amyloid kidney, 292. 

Amylum, 460. 

Anacidity, 201. 

Anal fissures, 251. 

Analgesic balm, 119. 

Anaphylaxis, 88. 

Anemia, lymphatic, 339. 

primary, 277. 

secondary, 280. 
Anesthesia, by water, 18. 

general, 25. 

local, 15. 
Angina pectoris, 255. 
Anise, 397. 

Anterior poliomyelitis, 317. 
Anthrax, 365. 

Antidiphtheritic serum, 125. 
Antipyretics, 31. 
Antipyrin, 22, 398. 
Antiseptics, 83. 
Antitoxin, diphtheritic, 125. 
Anuria, 283. 
Aphthae, 191. 
Apomorphin, 53, 136, 398. 

for convulsions, 72. 
Apoplexy, 270. 
Apothecaries' weights, 395. 
489 



490 



INDEX 



Argentamin, 457. 
Argonin, 458. 
Argyrol, 398, 457. 
Arnica, 398. 
Arsenic, 399. 

in dystrophia, 108. 

in skin diseases, 98. 
Arsenic pastes, 98. 
Arteriosclerosis, 269. 

pains of, 23. 
Arthritis, 346. 
Asafetida, 401. 
Ascites, 227. 
Aspiration of pericardium, 258. 

pleural, 156. 
Aspirators, 159, 160. 
Aspirin, 452. 
Asthma, 57, 136. 
Atropin, 401. 

for children, 126. 

in asthma, 57. 

in vomiting, 54. 
Auto-sero-therapie, 228. 
Auto-vaocination in cirrhosis, 228. 
Avicenna, 26. 
Azotorrhea, 360. 

Bacilli of dysentery, 365. 
Bacterial colitis, 240. 
Barberry, 403. 
Barber's itch, 35. 
Bartholinitis, 309. 
Baths, coM, 61. 

in common use, 391. 

in heart disease, 262. 

in phthisis, 167. 

permanent, 90, 91. 
Beck's paste, 109. 
Belladonna ointment, 14. 
Benzoin, 402. 
Berberis, 403. 
Be'ri-beri, 338. 
Beta-eucain, 16. 
Beta-naphthol, 434. 
Betula lenta, oleum, 452. 
Binswanger's dietary, 59. 
Birch, oil of, 452. 



Bismuth, 403. 

Bismuth subnitrate, 13, 54, 55, 103. 

Bladder, size of, 296. 

Bladder irrigation, 293. 

Blood, diseases of, 277. 

Blood letting, 151. 

Blood vessels, diseases of, 269. 

Blue ointment, 36. 

Bones, inflammations of, 108. 

Borax, 404. 

Boric acid, 404. 

Boroglycerin, 405. 

Bradycardia, 257. 

Brand bath, 29. 

Bromidia, 412. 

Bromids, 405. 

for croup, 124. 

in insomnia, 44. 
Bromural, 44, 406. 
Bronchial asthma, 143. 
Bronchitis, 134. 
Bronchitis tent, 135. 
Broncho-pneumonia, 137. 
Brucin, 461. 
Bruises, 95. 

of muscles, 105. 
Buboes, 339. 

Buffalo lithia water, 473. 
Burns, 90. 

Cade, oil of, 407. 
Caffein, 407. 
Calcium, 408. 

in hemoptysis, 184. 
Calcium sulphid in fever, 33. 
Calculus, renal, 292. 
Calories needed, 64. 
Calx sulphurata, 463. 
Camphor, 136, 409. 
Camphoric acid, 410. 
Cancer of stomach, 23, 204. 
Capillary hemorrhage, 274. 
Carbo animalis, 412. 
Carbo ligni, 412. 
Carbohydrates needed, 64. 
Carbolic acid, 446. 
Carbonic-acid baths, 262. 



INDEX 



491 



Carcinoma of esophagus, 195. 
Cardamomum, 410. 
Cardia, spasm of, 197. 
Cardiac neuroses, 255. 
Carlsbad water, 49, 471. 
Cascara, 50, 410. 
Castor oil, 50, 411. 
Cataplasma kaolini, 7, 121, 432. 
Catheterization, 294. 
Caustics, 89. 
Cerebro-spinal fluid, 316. 
Chalk, 408. 
Charcoal, 412. 
Chicken-pox, 366. 
Chloral hydrate, 43, 412. 
Chloretone, 44, 413. 
Chloretone inhalant, 56, 177. 
Chlorine -poor diets, 289. 
Chloroform, 413. 
Chlorosis, 277. 
Cholangitis, 221. 
Cholecystitis, 221. 

chronic, 224. 
Cholelithiasis, 225. 
Cholera, 366. 
Chorea, 323. 
Chronic bronchitis, 140. 
Chronic urethritis, 302. 
Cigarettes for asthma, 143. 
Circulation, influencing, 76. 
Cirrhosis of liver, 226. 
Citric acid, 413. 
Clay poultice, 78, 121. 
Climate for phthisis, 169. 
Coagulability of blood, 237. 
Coal-tar derivatives, 22, 413. 
Cocain, 15, 16. 
Codein, 441. 
Cohnheim's apparatus for dilating 

cardia, 198. 
Colchicum, 415. 
Cold baths, 28, 61. 
Cold sponging, 29. 
Cold-water coils, 30. 
Colic of infants, 230. 
Colica flatulenta, 229. 
Colica mucosa, 229, 237. 



Colica rheumatica, 229. 
Colica verminosa, 229. 
Colitis, 237. 

from metals, 239. 
Collargol, 261, 379, 458. 
Collodion, 415. 
Collodion stypticum, 465. 
Colloidal silver, 458. 
Colocynth, 416. 
Complementary space, 161. 
Condurango, 205, 416. 
Condylomata, 38. 
Congress water, 474. 
Constipation, 45. 
Convulsions, 71. 
Copper sulphate, 416. 
Cornstarch, 460. 
Coryza, 113. 
Cough, 55. 

of phthisis, 182. 
Counterirritation, 81. 
Creatinin excretion, 285. 
Creosote, 416. 
Cretinism, 344. 
Croup, 123. 
Cupri sulphas, 416. 
Cuts, 93. 
Cystitis, 293. 

De Bove's diet, 70. 

Demulcents, 81. 

De Wees's carminative, 401. 

Diabetes mellitus, 349. 

Diaphoresis, 31. 

Diarrhea of phthisis, 186. 

Diazyme, 444. 

Diet for emaciation, 59. 

in esophageal stricture, 196. 

in fever, 33. 

in hepatitis, 221. 

in infectious diseases, 364. 

in phthisis, 165. 

in typhoid, 234. 
Digitalin in pneumonia, 147. 
Digitalis, 417. 

for children, 126. 
Dilatation, gastric, 208. 



492 



INDEX 



Dionin, 441. 

Diphtheria, 124. 

Diphtheria serum, 86. 

Disinfectants for stools, 237. 

Disinfection of sick room, 363. 

Diuretin, 466. 

Dobell's solution, 101. 

Donovan's solution for emaciation, 

61. 
Dormiol, 44, 419. 
Dosage and age, 392. 
Douglass's solution, 102. 
Dover's powders, 380, 420, 441. 
Drip sheet, 62. 
Dunbar's serum, 448. 
Duotal, 426. 

Dysentery, bacillary, 365. 
Dysmenorrhea, 24. 
Dystrophia muscularis, 107. 

Eclampsia, 73. 
Edema glottidis, 124. 
Edema of the lungs, 144. 
Effervescent potass, citrate, 449. 
Electric light, 8. 
Electro-massage, 11. 
Elimination, 82. 
Elixirs, 420. 
Emaciation, 58. 
Embolism, 311. 
Emesis gravidarum, 53. 
Emollients, 81. 
Emphysema, 144. 
Encephalitis, 311. 
Endocarditis, 264. 
Endometritis, 308. 
Enemata, 51. 

nutrient, 203. 
Enteralgia, 229. 
Enteritis, 231. 
Enteroptosis, 244. 
Enuresis, 299. 
Epicarin, 421. 
Epididymitis, 306. 
Epilepsy, 324. 
Epileptic seizures, 73. 
Epinephrin, 421. 



Epistaxis, 116. 
Ergot, 422. 

in anuria, 284. 

in shock, 91. 
Ergotoxin in shock, 58. 
Erysipelas, 370. 
Esophageal stricture, 216. 
Esophagus, inflammations of, 193. 

length of, 212. 
Ether, 422. 
Ethyl chlorid, 423. 
Ethyl oxid, 422. 
Eucain, 423. 
Eucalyptol, 104, 424. 
Eucalyptus, 424. 
Evening rub, 62. 

Excelsior Springs waters, 480, 481. 
Exercises for phthisis, 168. 
Exophthalmic goiter, 344. 
Expectorant mixture, 136, 139. 
Eye wash, 459. 

Fats needed, 64. 
Feces, disinfection of, 237. 
Ferrous carbonate, 431. 
Fever, 26. 

of phthisis, 181. 
Fibrolysin, 89, 424. 

in pericarditis, 258. 
Fissure in ano, 251. 
Fistula in ano, 251. 
Flatulence, 233. 
Fletcher, Horace, 64. 
Fomentations, hot and cold, 7. 

to chest, 149. 
Food values, 68, 69, 350. 
Formaldehyd, 425. 
Fox-glove, 417. 
Friar's cowl, 396. 
Friction, 9. 

Friedrichshall water, 472. 
Frostbite, 93. 

Gallotannic acid, 464. 

Gall-stones, 225. 

Gangrenous stomatitis, 192. 
Gant, 18. 



INDEX 



493 



Gastralgia, 200. 

Gastrectasis, 209. 

Gastric ulcer, 203. 

Gelatin for hemorrhage, 275. 

Gelsemium, 425. 

in fever, 32. 
Gentian, 426. 
Geographical tongue, 192. 
German measles, 376. 
Glanders, 371. 
Glands, 339. 

enlarged, 197. 
Glonoin, 437. 

Glyceritum acidi tannici, 465. 
Glycosuria, 355. 
Golden seal, 426. 
Gonorrhea, 301. 
Gouget diet, 288. 
Gout, 345. 
Guaiacol, 426. 

as antipyretic, 32. 

for obesity pains, 71. 

in pleurisy, 155. 
Guarananine, 407. 
Gummata, hepatic, 226. 

Hathorn water, 475. 

Hay fever, 117. 

Headache in infectious diseases, 364. 

Heart, diseases of, 255. 

in constitutional diseases, 266. 
Heat centers, 31. 
Heat for pain, 6. 
Hebra's itch ointment, 36. 
Hebra's ointment, 97. 
Heitzman's hemorrhoidectomy, 250. 
Hellebore, 470. 
Hematoporphyrinuria, 286. 
Hematuria, 286. 
Hemoglobinuria, 286. 
Hemophilia, 276. 
Hemoptysis, 183. 
Hemorrhage, capillary, 274. 

in typhoid, 236. 

intracranial, 311. 
Hemorrhagic pleurisy, 162. 
Hemorrhoids, 250. 



Henock's pack, 138. 

Hepatitis, 220. 

Heroin, 56, 137, 440. 

Herpetic stomatitis, 191. 

Hexamethylenamin, 426. 

Hiccough, 54. 

Hinkle's cascarin compound, 364. 

Hodgkin's disease, 339. 

Hoffman's anodyne, 423. 

Holadin, 443. 

Hookworm, 243. 

Hot air, 11. 

Hot-air baths for icterus, 218. 

Hot-air cabinet for obesity, 70. 

Houghton's soup, 235. 

Hunyadi Janos water, 472. 

Hydatid cyst, 228. 

Hydrargyrum, 433. 

Hydrastinin, 427. 

Hydrastis, 426. 

Hydrocephalus, 312. 

Hydrochloric acid in anacidity, 201. 

Hydrogen peroxid, 427. 

Hydronephrosis, 292. 

Hydrophobia, 371. 

Hydrotherapy in hysteria, 331. 

in neurasthenia, 333. 
Hyoscin, 44. 

Hyoscin hydrobromid, 428. 
Hyoscyamus, 428. 
Hyperacidity, 202. 
Hyperemia, 7, 8, 80, 94, 149. 
Hyperthyroidism, 344. 
Hypnotism, 328. 
Hypodermic medication, 19. 
Hypodermoclysis, 283. 
Hypoglycemia, 360. 
Hypothyroidism, 344. 
Hysteria, 73, 230, 325. 

Ice bags, 30. 

Ichthyol, 428. 

Icterus, 217. 

Ileocolitis, 232. 

Ileus, 230. 

Impotence, 306. 

Infantile cerebral palsy, 312. 



494 



INDEX 



Infectious diseases, 363. 
Inflammations, acute, 75. 

chronic, 83. 

of biliary passages, 221. 

of kidney, 285. 
Influenza, 373. 

Inhalations for phthisis, 176. 
Injections, intramuscular, 92. 

intravenous, 92. 
Insomnia, 41. 

of pericarditis, 260. 
Insufficiency of heart, 267. 

of kidney, 287. 
Intestines, diseases of, 229. 
Intoxications, 82. 
Intracranial disorders, 310. 
Intramuscular injection, 21, 92. 
Intravenous injection, 21, 92. 
Intubation, 127. 
Intussusception, 230. 
Invagination, 230. 
Iodids, 386, 428. 

in pleurisy, 155. 
Iodin inhalant, 123, 177. 
Iodized lime, 122. 
Iodoform, 429. 
Iodoform inhalant, 176. 
Ipecac in colitis, 242. 
Ipecacuanha, 429. 
Iron, 431. 

Iron preparations, 278. 
Irrigation, of bladder, 293. 

principles of, 100. 
Itching, 34. 
Itrol, 457. 
Ivy poisoning, 38. 

Kaolin, 432. 
Karel cur, 261, 265. 
Kidneys, diseases of, 282. 
Kissingen water, 471. 
Kneading, 9. 

Lactic acid, 432. 
Lactic-acid therapy, 232. 
Lanolin, 485. 
Laryngeal tuberculosis, 186. 



Laryngismus stridulus, 123. 
Laryngitis, 122. 
Laryngospasm, 362. 
Larynx, tuberculosis of, 23. 
Lavage, gastric, 210. 
of esophagus, 196. 
Lead colic, 230. 
Leiter coils, 30. 
Leukemia, 280. 
Leukoplakia oris, 193. 
Lime, iodized, 122. 
Lime water, 408. 
Linimentum camphorse, 410. 
Liquor cresolis compos., 417. 
Liver, diseases of, 216. 
Local anesthesia, 15. 
Localized inflammations, 75. 
Loeffler's solution, 126. 
London paste, 99, 458. 
Lugol's solution, 117. 
Lumbar puncture, 313. 
Lupus, 99. 

Luxus consumption, 64. 
Lycetol, 292, 447. 
Lymphadenitis, 339. 
Lysidin, 447. 
Lysol, 433. 

Magnesium sulphate in tetanus, 320. 

Malaria, 375. 

Male fern, 241. 

Mania, 321. 

Manitou water, 476. 

Massage, 9. 

of colon, 48. 

of prostate, 305. 
Meadow saffron, 415. 
Measles, 375. 

Meningeal convulsions, 73. 
Meningitis, 312. 
Mentha piperita, 444. 
Menthol, 13, 410. 
Menthol tablets, 118. 
Mercurial ointment, 35. 
Mercurial stomatitis, 191. 
Mercury, 384, 433. 

ammoniated, 96. 



INDEX 



495 



Mercury succinimid, 178. 
Mesotan, 453. 
Methyl salicylate, 452. 
Methylene blue, 434. 
Methylioninse hydrochlor., 434. 
Metric equivalence, 395. 
Milk, in nephritis, 288. 

substances excreted in, 392. 
Mineral waters, 231, 470. 
Monkshood, 396. 
Monobromated camphor, 409. 
Morbilli, 375. 
Morphin, 18, 440. 

in pleurisy, 155. 
Mount Clemens water, 477. 
Mousebane, 396. 
Mucous membrane, inflammations of, 

100. 
Muscles, inflammations of, 105. 

injections into, 92. 
Mustard poultice, 78. 
Myalgia, 106. 
Myelitis, 317. 
Myocarditis, 260. 
Myxedema, 344. 

Naphthol, 36, 96, 434. 

Natrum, 458. 

Nauheim treatment, 262. 

Needles, 20. 

Neoplasms, intracranial, 312. 

Nephritin, 283. 

Nephritis, 23. 

acute, 285. 

chronic, 286. 

heart in, 266. 
Neuralgia, 336. 
Neurasthenia, 333. 
Neuritis, 337. 
Neuroses, 320. 

gastric, 207. 

of heart, 255. 
Nitrites, 435. 

in asthma, 57. 
Nitroglycerin for children, 126. 
Nitrous oxid, 438. 
Noma, 192. 

33 



Normal solutions, 453. 
Nursing precautions in cholera, 367. 
Nutrient enemata, 203. 
Nutritive ratios, 68. 

Obesity, 63. 

Obstruction of bowels, 230. 

Ocean water, 471. 

Oertel's diet, 70. 

Oil of sandalwood, 455. 

of sweet birch, 452. 

of turpentine, 469. 

of wintergreen, 452. 
Ointments, 14, 35. 

for pain, 119. 
Oleata, 223. 
Oleum cadinum, 407. 

santali, 455. 
Oophoritis, 308. 
Opium, 439. 
Orange, syrup of, 463. 
Orange root, 426. 
Orchitis, 306. 
Organic iron, 278. 
Orthoform, 103, 442. 
Osteomyelitis, 108. 
Otitis media, 378. 
Ovoferrin, 431. 
Oxaluria, 284. 
Ox gall, 222, 442. 
Oxycamphor, 410. 

Pachymeningitis, 317. 
Pack, hot, 31. 
Pagosa water, 478. 
Pain, 5. 

local treatment of, 6. 
Palpitation, cardiac, 255. 
Pancreatin, 443. 
Pancreatitis, 245. 
Papain, 444. 
Paracentesis abdominis, 227. 

pericardii, 258. 
Paralysis, diphtheritic, 134. 
Parasites, in itching, 35. 

intestinal, 241. 



496 



INDEX 



Paresis, 311. 

Peppermint, 444, 

Pepsin, 445. 

Percussion, 11. 

Pericarditis, 257. 

Pericardium, aspiration of, 258. 

Periostitis, 108. 

Peritonitis, 246. 

Permanganate of potash, 445. 

Pernicious anemia, 279. 

Pest, 376. 

Petrolatum, 445. 

Pharyngitis, 117. 

Phenacetin, 22. 

Phenol, 446. 

Phenolated camphor, 410. 

Phenolphthalein, 446. 

Phenylis salicylas, 455. 

Phlebotomy, 151. 

Phosphaturia, 285. 

Phosphoric acid, 150. 

Phosphoric-acid excretion, 285. 

Phosphorus, 447. 

Photophore, 8. 

Phthisis, 164. 

Pinworms, 243. 

Piperazin, 292, 447. 

Pituitary body, 342. 

Pix liquida, 466. 

Plague, 376. 

Pleuresie bloqu6e, 163. 

Pleurisy, 154. 

of phthisis, 187. 
Plummer's dilator for cardia, 199. 
Pluto water, 479. 
Pneumonia, 145. 
Pneumonia jacket, 145. 
Pneumothorax, 187. 
Pollantin, 117, 448. 
Portal congestion, 206. 
Potassii permanganas, 445. 
Potassium compounds, 448. 
Poultices, 77 et seq. 
Powders for itching, 37. 
Priessnitz bandage, 7, 121. 
Probilin, 224. 
Proctolysis, 247. 



Prostatitis, 304. 
Protargol, 458. 
Protein needed, 64. 
Pruritus, 39. 

ani, 253. 

of icterus, 218. 
Pseudoleukemia, 339. 
Ptomain poisoning, • 73. 
Pulvis acetanilidi comp., 408. 
Pulvis antisepticus, N. F., 13. 
Pulvis antisepticus solubile, 39. 
Purpura, 275. 
Pyloric stenosis, 205. 
Pyorrhea alveolaris, 192. 

Quetelet's tables, 65. 
Quinin, 450. 

in pneumonia, 148. 
Quinin hydrobromate, 344. 

Rabies, 371. 
Ratio, nutritive, 68. 
Rectum, diseases of, 250. 
Red Raven water, 479. 
Reeducation, 326, 329. 
Regent water, 480. 
Relaxed vessels, 272. 
Renal calculus, 292. 
Resorcin, 103, 451. 

compound, ointment, 97. 
Resorcin ointment, 37. 
Resorcinol for tonsillitis, 119. 
Respirator, 140. 
Rest, 79, 81. 

Rhamnus purshiana, 410. 
Rheum, 451. 
Rheumatism, 346. 
Rhinitis, 113. 
Rhubarb, 451. 
Rickets, 361. 
Ringer's solution, 453. 
Ringworm, 35. 
Rochelle salts, 451. 
Round worms, 244. 
Rubella, 376. 
Rubeola, 376. 



INDEX 



497 



Sabromin, 452. 
Salicin, 453. 
Salicylates, 452. 

in myalgia, 106. 
Saline solution, 453. 
Salol, 455. 
Salophen, 453. 
Salpingitis, 308. 
Salt free diets, 289. 
Salt glow, 62. 
Salts, cathartic, 49. 
Sanatoria for phthisis, 170. 
Sandalwood oil, 455. 
Sand bag, 7. 
Santonin, 456. 

Saratoga Congress water, 474. 
Saratoga Hathorn water, 475. 
Saratoga Vichy water, 482. 
Scabies, 35. 
Scarlet fever, 377. 
Schleich's solutions, 16, 17. 
Schott movements, 267. 
Schott treatment, 262. 
Sciatica, 17. 

Scorbutic stomatitis, 192. 
Scurvy, 276. 
Sea water, 471. 
Seasickness, 53. 
Seat worms, 243. 
Seidlitz water, 472. 
Senna, 456. 
Septicemia, 378. 
Serous membranes, inflammations of, 

104. 
Serum therapy, 86. 
Shaeffer and Coleman, 235. 
Shock, 57, 91. 
Siloam water, 480. 
Silver, 457. 

nitrate, 103. 

vitellin, 398. 
Simaruba, 232. 
Skin, inflammations of, 89. 

bacterial, 95. 
Sleeping sickness, 281. 
Smallpox, 380. 
Sodium, 458. 



Sodium acetate, 6. 

nitrite, 437. 

oleate, 223. 

succinate, 223. 
Soluble antiseptic powder, 39. 
Solutions by percentage, 394. 
Soup, vegetable, 235. 
Spasm of cardia, 197. 
Spasmodic laryngitis, 123. 
Spermatorrhea, 306. 
Spinal analgesia, 317. 
Spinal fluid, 315, 316. 
Splanchnic neurasthenia, 273. 
Spleen, 341. 
Splenomegaly, 341. 
Spongia combusta, 122. 
Sprays, alkaline, 115. 
Starch, 460. 
Steam for cough, 56. 
Steatorrhea, 360. 
Stenosis, pyloric, 205. 
Stomach, dilatation of, 208. 

lavage of, 210. 
Stomach solutions, 102. 
Stomach tubes, 211. 
Stomatitis, 188. 
Stools, disinfection of, 237. 
Strains, 106. 
Stramonium, 460. 
Stricture of esophagus, 194. 

spasmodic, 197. 
Stroking, 9. 
Strychnin, 461. 

for children, 126. 

in shock, 92. 
Strychnin poisoning, 73. 
Stypticin, 462. 
Styptol, 462. 
Succinates, 223. 
Sulphonal, 462. 
Sulphonmethanum, 462. 
Sulpho-saline water, 481. 
Sulphur, 463. 

compound, ointment, 97. 
Sulphur ointment, 35, 96. 
Sunstroke, 312. 
Suppositories, 252. 



498 



INDEX 



Suppurative peritonsillitis, 117. 
Suprarenal glands, 342. 
Sweats of phthisis, 182. 
Sweet spirits of niter, 437. 
Syncope, 162. 
Syphilis, 384. 
Syphilitic buboes, 339. 
Syringes, 19. 
Syrup of orange, 463. 
of Tolu, 468. 

Tabes cerebralis, 311. 

dorsalis, 318. 
Tables of weight, 65, 66, 67. 
Tachycardia, 257. 
Taenia, 241. 
Talc, 463. 

Talcum powder, 38. 
Tannalbin, 465. 
Tannigen, 465. 
Tannin, 464. 
Tannoform, 465. 
Tannopin, 465. 
Tapping the abdomen, 227. 
Tar, 104, 466. 

Tartrate of potash and soda, 451. 
Tendons, inflammations of, 105. 
Tetanus, 319. 
Tetronal, 462. 
Thein, 407. 
Theobromin, 466. 
Theocin, 467. 
Thiosinamin, 467. 
Thoracocentesis, 156. 
Throat lozenges, 118. 
Thrombosis, 311. 
Thrush, 190. 

Thymol, 103, 243, 344, 468. 
Thymol inhalant, 142. 
Thyroid extract, 468. 
Thyroid gland, 343. 
Tolu, 468. 
Tonsillitis, 118. 
Tooth powder, 188. 
Toxic colitis, 239. 
Toxic neuritis, 338. 
Tracheotomy, 131. 



Trichloracetic acid, 99, 468. 
Trimethyl xanthin, 407. 
Trional, 44, 462. 
Trousseau's bougies, 198. 
Trypan red, 281. 
Trypanosomes, 281. 
Tubage of esophagus, 194. 
Tuberculin, 180. 
Tuberculosis of bones, 109. 

of glands, 340. 

of peritoneum, 249. 
Turpentine, 469. 

for cough, 56. 
Turpentine pipe, 141. 
Typhoid fever, 234. 

heart in, 266. 

Ulcerative stomatitis, 191. 
Ulcers, intestinal, 90. 

of stomach, 203. 

pain of, 12. 

varicose, 272. 
Uncinaria, 243. 
Unguentum Crede, 379. 

hydrargyri ammoniati, 36. 

hydrargyri dilutum, 36. 

resorcini co., 37. 

sulphuris compositum, 36. 
Urea, 469. 
Uremia, 73, 282. 
Urethritis, 300. 
Urinary solids, 287. 

Vaccination, 85. 

for smallpox, 382. 

for urethritis, 302. 
Vaccines, 88. 

Vaginal douches, 102, 459. 
Valerian, 470. 
Valyl, 470. 
Vapor for cough, 56. 
Vapor massage, 10. 
Varicella, 366. 
Varicose ulcers, 272. 
Varicose veins, 271. 
Variola, 380. 
Vegetable days, 357. 



INDEX 



499 



Vein, injection into, 92. 
Venereal buboes, 339. 
Venesection, 151. 
Veratrum viride, 185, 470. 
Veronal, 44, 470. 
Veronica water, 49, 481. 
Vibration, 10. 
Vichy water, 471. 
Vichy water (Saratoga), 482. 
Vienna paste, 99. 
Vinegar, 396. 
Voit's calories, 63. 
Vomiting, 52. 
of phthisis, 183. 

Warts, paste for, 100. 
Water for constipation, 50. 
Waters, 470. 
Wechsel douche, 273. 
Weight equivalents, 395. 



Weight tables, 65, 66, 67. 
Weir-Mitchell dietary, 59. 
White precipitate ointment, 
White Rock water, 483. 
Wilkinson's ointment, 97. 
Wilkinson's salve, 36. 
Wintergreen, oil of, 452. 
Witter Springs water, 484. 
Wolf's bane, 396. 
Wool fat, 485. 
Wright, Sir A. E., 237. 

Yellow fever, 369. 
Yellow jasmine, 425. 
Yellow puccoon, 426. 
Yellow root, 426. 
Yohimbin, 486. 

Zinc compounds, 486. 



36. 



(1) 



THE END 



AUG 3.0 I9EG 



One copy del. to Cat. Div. 



AOQ 



?& mm 



